This podcast episode was recorded on 14 February 2020 and does not take into account more recent developments of the ongoing coronavirus (COVID-19) pandemic. This episode focuses on China's initial response to the virus where it originated, the World Health Organisation's (WHO) responsibilities with regard to responding to an outbreak of this scale, and the challenges in dealing with misinformation in a highly connected digital age.
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The world responds to the novel coronavirus outbreak
David Austin: In light of the COVID 19 virus that continues to plague China and other countries, we caught up with
Tikki Pangestu, Visiting Professor at the Lee Kuan Yew School of Public Policy. You are absolutely the man in demand right now. Your expertise really matches what's happening right now with the COVID-19. 13 years at the World Health Organization in Geneva as Director of Research Policy and Cooperation Department, and I know you've been speaking a lot...
Tikki Pangestu: Just a quick wrap up on the current situation - I think the situation remains pretty grave in China so, I think that is going to be a continuing challenge for the Chinese government to deal with, but at the same time, despite a lot of the rumours that are spreading around, I think they're doing the best that they can. I do not think there is any issue of them massaging or hiding figures, it's just that the situation is moving so quickly, and they could be a little bit overwhelmed in terms of their capacities to test people.
David Austin: In the latest developments, do we know anything more about the virus itself, like as far as its virulence or its spread? What else have we learned so far?
Tikki Pangestu: As far as I'm aware, there's been no new evidence, at least that I've heard that there's been any change. The technical term is a mutation in the virus that makes it able to cause more severe disease or be able to spread more easily. For example, people have been talking about airborne spread rather than droplets or close contact. I have not seen any, recent evidence, at least not in the past, four or five days that indicates that that's happening. Thank God.
David Austin: And what about, any work on a vaccine?
Tikki Pangestu: Yeah, obviously, a vaccine is one of the best strategies to mitigate the problem. But, unfortunately, a vaccine is very much a longer term solution, and by the time a vaccine is ready, you're talking in the best possible scenario, six months, more likely a year to 18 months. Now, with the caveat that when Ebola hit West Africa, they did what they call a fast track development. The issue is not so much the development of a possible vaccine. The issue more is to make sure that it's safe to be given to people. So, in the case of Ebola, they fast track the development.
They got permission with support from WHO to fast track its introduction into people without all the usual experiments that normally, they will have to do before they are given a license to actually use it in humans. So, depending on how the situation evolves, that might happen. But given history, I would say that by the time the vaccine is ready now, the outbreak would be over. Yeah. But that's not to say that it won't be helpful to have for any future outbreaks of this virus.
David Austin: And what about just on the treatment front, has there been confirmation of what is the best way to treat patients?
Tikki Pangestu: Yeah. At the moment, there is a lot of quackery out there. There's something about rubbing sesame oil on your back, there's something about garlic and onion, herbs. That's total misinformation. Fake news, if you like. At the moment because it's a virus, there are no obvious treatments. I believe that, there was an anti-virus medicine produced by Gilead in the United States that the Chinese was sort of set to have tried, but I have no data as to where, how many patients, whether it worked or not.
But I do know for a fact that many labs in China are pursuing the possibility of an antiviral medicine. Obviously in this case, antibiotics will not be of much use. So, the only treatment is to take care of the symptoms. Okay.
David Austin: Do we know yet, do recovered victims retain an immunity to this or can they be reinfected?
Tikki Pangestu: I think it's probably too early to say, because you're talking about patients who have recovered just within the last, you know, weeks after getting the infection.
So, only time will tell, but on basic, epidemiological principles, I would say, there would be a window where they would be protected from a second infection, assuming it's the same virus. It goes back to your original question, if the virus mutates or changes. Like what happens with the flu virus, and if there is theoretically a second wave with a new virus, it's likely that these people may not be protected, but if it's the same virus, just off the top of my head they would probably be protected for at least six months to a year if the same virus comes back.
David Austin: So I wanted to go back to description of China, because I know in some of the other questions, at least compared to SARS, people were giving China a lot of credit for acting better at this time and for learning the lessons... But are we being too kind in our assessment of China? Are they are they doing enough? There are still quite some horror stories coming out as far as, you know, the treatment of patients, the doctor dying, the mistreatment of frontline staff-
To answer, let me sort of try and get at it from a slightly different angle. At the level of the Chinese Ministry of Health in Beijing, I believe they continue to be very transparent and open, in terms of sharing the data regarding the virus as well as the disease itself, especially with the WHO.
And it goes back to what you said earlier. I think they really learned a big lesson after SARS that, you know, in the context of, let's say, international solidarity, viruses don't need visas and passports to cross borders, that if they do not behave as a good, let's say, global citizen, they risk becoming an international pariah, which is what happened after SARS.
They were widely condemned for hiding the real situation. So, I believe at the level of the Minister of Health, they continue to be open, to be transparent. The second point and a caveat to this is, I would say they are doing the best that they can, taking into account the magnitude of the problem that they're facing, possible limitations in both clinical care workers as well as laboratory workers to do the diagnosis. All the other medical support workers, people who are doing x-rays, the nurses in the hospital, they're probably facing a bit of a crisis. [The] situation is changing all the time. And this, I believe, this is my own personal view, is complicated by the fact that there is probably a communication gap between what the Central Government wants people to do and what happens at a provincial level, what happens at the level of cities, for example. Now you mentioned the case of the doctor who died. Totally unfortunate, but I believe in that particular situation, you know, China has a very strict hierarchy power system. In that particular case, the mayor of Wuhan did not have any authority to make a decision on his own. He might have been well aware of the risk, I don't know. But he could not sort of make a decision to say, "Hey, there may be something in this. Let us investigate." I think his hands are tied. So that is some sort of, I don't know, maybe some governance weaknesses in the links of command.
I'm not making excuses; I think overall the government is still committed to sharing.
David Austin: Can you share with us any insight of what it's like at the World Health Organisation behind closed doors when crises like these arise and you've got, the world's media, all the eyes of the world are on the WHO. How do they function?
Tikki Pangestu: Very good question. And, I was at WHO when SARS happened, and the fallback of the organisation is always: what is the evidence? So, we do this through various ways. And as you know, with COVID-19, for the past three weeks, even a month, we have had an emergency committee working in Geneva. This is an independent group of international experts who are not WHO staff members, who have the expertise and who closely monitor the report from the countries. So, the WHO first and foremost relies on reporting for countries. And what a lot of people don't realise is that countries actually have a legal, moral obligation to report cases like this to the WHO. So it looks at data from the countries, but at the same time, it relies on this independent group of experts to say, "Hey, what do we do next?" And as you know, this expert committee had been deliberating for the last two or three weeks.
They delayed the announcement or the Public Health Emergency of International Concern (PHEIC) based on the existing evidence. So, I believe it's a very open, a very transparent, a very independent process based on scientific evidence. And that's to me, the only way to move forward. At the same time, as you mentioned, for political reasons, Declaring a PHEIC is not something that WHO takes lightly.
Now, why is that? It has a lot of implications and repercussions. And it's a situation [that] when I reflect back is 'if you do, you're damned, if you don't, you're damned'. If you do - H1N1 in 2009, swine flu, we declared a PHEIC. And nothing really happened. The disease was mild. Yes, it spread very widely, very mild.
There were no fatalities, at least not many. And WHO was accused of overreacting, creating panic, hysteria, causing economic impacts, etc. So, we were a bit stung by that. So this time, perhaps a bit more careful. In the case of Ebola, there was no hesitation. It spread tens of thousands of cases, 30% death rate, no question.
We didn't deliberate. In this case, it was like, once again, a new situation. Huge problem in China. Was it a global pandemic? Maybe not. Low fatality rate, many cases recovered, like in Singapore, they have been discharged. That's why they deliberated. At the end of the day, they decided for whatever reason, based on evidence, yes, we'll declare it.
So, in a way they played it safe, but as I said, it has a lot of repercussions. And, perhaps in relation to this, WHO can issue a declaration like that, but it cannot enforce it on countries. You know, WHO is not an international government that can enforce, and as you know, many countries actually went against the WHO recommendation. I mean, the US is a clear example. Because WHO very clearly said, "Don't impose travel bans," and yet that's what the US did. And I think maybe 10 other countries. So, you know, people need to understand what WHO can and what WHO cannot do.
I still remember, during Ebola 2014-15, WHO was very severely criticised for being slow to react, not helping countries. And what I like to tell people is that, WHO is not an organisation that can send a hundred doctors, a hundred nurses, a hundred field hospitals halfway around the world in 48 hours. It is not an emergency response organisation. So I thought during Ebola we were unfairly criticised and maybe this time around WHO was a little bit more cautious. I leave it at that, I can go on for hours on this-
David Austin: Well I'd like to know more about what WHO can do as far as their mandate, besides just declaring a PHEIC, what other levers do they have to pull and what decisions do they have to make, besides just the big obvious decision of 'is this a crisis or not?'
Tikki Pangestu: Okay. So, the bigger decisions they have to make, and it's quite obvious, one of their main mandates is strengthening the ability of countries to take care of the health of the people, including situations like this. They are able, in fact, what I believe is their most important function, is to set norms and standards or best practices. Like in the case of outbreaks like this, and on which the PHEIC is based, WHO developed, back in 1969, something called the International Health Regulations. Now that's an international legal instrument, that all countries sign up to, that all countries commit to implementing the various recommendations, including prompt reporting of cases like this. Including telling WHO if they're going to close borders. So that's the first one, setting norms and standards.
The second one that's very important is convening power. WHO has tremendous convening power. Whenever something like this happens or even other sort of more controversial areas; patents around medicines is another area. It can bring everybody together around the table and say, "Let's collectively work together to solve our problem." In this case, for example, they are able to convene the World Bank. They're able to convene the European Union. They can call Mr. Gates in Seattle [and say] "Hey, we have an international crisis here. We have established something called the PEF (Preparedness Emergency Fund). We need all of you to donate to this fund so we can help countries like African countries to prepare for that. So, convening power that's unparalleled.
I still remember, when I was working at WHO, whenever I needed to convene an expert committee, like you know, the one that's going for COVID, all I had to do was pick up the phone. The top people, the Nobel prize laureates, top scientists, they would come, without any expectation of payment. That's the convening power.
The third function is what we've already seen, information clearing house. As I said, there's a legal obligation. As you know, if you look at the last four or five days, you see all kinds of numbers from all kinds of sources in terms of the number of deaths, number of countries, etc. And it's very confusing. WHO is the clearing house. So I always tell people, go to the WHO website for the latest, most reliable estimates. So that's the information clearing house.
The fourth which is no less important, is what I mentioned at the beginning, helping countries with technical support. [WHO] cannot give money, it doesn't have a lot of money. Would you know that the annual budget of WHO, with 160 country offices six regional offices, is about $2 billion? That's the budget of a medium-sized hospital in the United States. That puts it into perspective, but it provides technical expertise to countries in terms of how they can strengthen their health system to better prepare, not just for epidemics, but for other diseases. So that's basically what it can do.
But in the context of COVID I think what I would like to emphasise is that perhaps its main aim is to continue building international trust and solidarity when something like this happens. And that's one of the reasons they do not recommend travel bans. Can you imagine, if the United States bans travel from one country, the minute you lock down a country, you're going to have problems. That country is going to say, "Hey you're going to ban me. You're going to affect all my citizens. You're going to affect my economy; the next time something happens in my country, I'm not going to tell anybody." You see the potential repercussions, so you know the overall [aim] is [to] maintain international trust, maintain solidarity, so that people continue to share information. Sorry I get carried away.
David Austin: No that's good, I can appreciate the passion and I know it comes from experience. Do you want to share with us the things that WHO cannot do?
Tikki Pangestu: I have already mentioned, emergency response. It really is about setting norms and standards. You know, at WHO in Geneva, only a small percentage of our staff are medical doctors, and most of them are not doing patient care work. We don't have laboratories. We don't have logistics support in terms of flying equipment. We don't have stockpiles of medicine. So emergency response is something we cannot do. The other thing we cannot do is provide immediate financial support because whatever budget WHO has, is mostly spent on the normative work.
It's mostly spent on convening expert committee meetings. A lot of it is in terms of developing documents, for example, around guiding countries, what is the best treatment for malaria? What is the most reliable test for COVID? So, it's mostly to support their technical work, so it doesn't have resources to directly give financial help to countries. So, these are the two main ones that come to mind.
And thirdly, what I already mentioned, it has no power to enforce countries to follow the recommendations. You know, the way I've always seen it expressed is that it has a lot of moral authority, it relies on solidarity. If China hide something, it will be condemned by the rest of the world. So, it cannot enforce things. Now, I saw a very interesting article just few days ago. How can that be changed? How can WHO have more, "clout" in terms of, let's say "punishing" countries that don't follow the recommendations.
And the interesting suggestion was why doesn't, WHO work with, for example, the G20, to establish a coalition of countries, that sort of agree that they will follow WHO recommendations, and the countries that don't will be subjected to trade sanctions? You know, it's really a bit out of the box, but somebody is thinking, you know, how can these norms and standards being enforced more forcefully, which at the moment it can't be, more moral authority.
David Austin: Moral authority is what you have. When it comes to emergency response, is the WHO giving advice or setting standards for that as well?
Tikki Pangestu: No, absolutely. This expert committee that's been meeting and still continues to meet, they've formed a small team that have gone together with the EU delegations to go to China specifically to help the Chinese deal with this, and obviously they will be, continuing to sort of, analyse the evidence in terms of, maybe even revising the International Health Regulations in light of new information that can come up during the crisis.
David Austin: What are some of the emergency response organisations that are out there?
Tikki Pangestu: That's a good question. And I go back once again to the experience we had with Ebola in West Africa. What you're dealing with is an acute emergency situation where the local hospitals are being completely overwhelmed, people are dying. There are no medicines, there are not enough facilities to quarantine and people are dying. So, in West Africa, in the three countries, Liberia, Guinea and Sierra Leone, the frontline responders were Doctors Without Borders, (MSF Medicine Sans Frontiers), the International Red Cross, a couple of other NGOs. The point of that was they first responded, together with whatever limited, local government facilities there were. Within a week, they were completely overwhelmed. And I'm going to throw back the question at you. Do you remember which was the most effective organisation who helped to deal with the Ebola crisis? Do you remember?
David Austin: No, I don't
Tikki Pangestu: If you think about it, it makes sense. The organisations that came in within a week, understanding the gravity of the situation was actually the US military, the US Armed Forces. If you think about it, the US armed forces have 2000 doctors working for them, I think 5,000 nurses. They have the command structure. They have these huge air force transports. They were able to mobilise a hundred doctors, hundred nurses, 2000 tons of equipment, set up 50 field hospitals within 72 hours. No other organization would have that.
Not only that, and I go back to international solidarity, in the case of Ebola, it wasn't just the United States. France, the UK, Germany, and get this China, they sent emergency medical teams to help the West African countries. I believe that when it comes to situations like this, all your conspiracy theories about the Americans releasing a bioweapon, I don't take that at all. I mean, I believe that most countries will appreciate the value of solidarity in terms of saving humanity. That's all there is to it. So those are the main, responders in this case.
In the case of China, I would say that it obviously would be quite sensitive for the US Armed Forces to fly into Wuhan unless the Chinese requested it. That's an entirely different story. And whether Mr. Trump would even agree, that's another story as well. I think in the case of China, I would say their armed forces are well capable of helping. So far, I've not seen, they've been really deployed, at least not in terms of patient care, but I think they have a very capable, sort of reserve there if they need it. Obviously at the moment, I think the frontline health workers [are] still a little bit over overwhelmed. I'm a little bit concerned actually at the number of fatalities. You know, that is really an indication of, maybe lack of the right sort of equipment and facilities within these hospitals. I don't know that part of it. I haven't seen much information.
David Austin: Now I know you're consistently concerned about developing countries whose health systems are not as strong, and you mentioned now that many Chinese workers are going to be returning to Africa, and that you worry about the possible spread. Of these countries, .. Which one worries you the most? Is there a weak spot that you're really worried about?
Tikki Pangestu: Well, you know, it's, once again, potentially sensitive issues, but basically, as you know, as part of the Belt and Road Initiative, China has huge investments in multiple African countries, both West Africa as well as East Africa. I don't really want to name the countries, but there are hundreds of thousands of Chinese workers building infrastructure projects, roads, ports, airports, and I would say, with perhaps a few exceptions, and in the category of the exceptions, I would put maybe South Africa, Tanzania, could be Uganda, a few others. Some of these countries have pretty good health systems, but the rest, you know, like the Democratic Republic of the Congo (DR Congo), for example, they are still dealing with an ongoing Ebola outbreak. If they get hit with this over and above that, they're going to be in real trouble.
So generally speaking, I think all African countries would not be too well prepared if something like this happens. Having said that, I think, as I said, here's been a window of opportunity, this past weekend, maybe the rest of this week, to maybe get enough testing kits sent to them to them, enough mask enough, fever scanners, whatever they need, so when these people come back, they are able to be at least screened on entry, hopefully minimise the possibility.
David Austin: Okay, so that's something we'll be watching in the next couple of weeks. Hopefully they are going to implement some sort of protocols as this population returns. I want to just wrap up with a couple of more local concerns. Like you mentioned - masks. What's the deal with masks?
Tikki Pangestu: Yeah. I mean, you know, despite what the government says, every day, the front page of the Straits Times, "Don't wear masks unless you are ill." And as I said before, many times good, hand washing habits is much more important than wearing masks. But I blame this partly because, you know, during SARS, we didn't have to deal with social media to the extent that it is today. 18 years ago, it wasn't like that. So, you know, with the population at large, perception is reality, whatever is the truth.
So, they see all these news, people in Hong Kong, China, everybody wearing masks, and the government here announces we're giving four to every household... so, you know, people sort of take the precautionary principle. If you ask me, it's not necessary unless of course you're not feeling well. You know, hand washing is much more important. It's probably a psychological thing.
David Austin: And then the last question is just about, you mentioned social media and the way that that has totally changed the game, and perception is reality. Obviously there's been lots of panics and scares, do you see anyone that is helping in any way, like providing some sort of fact check or or consistent message?
Tikki Pangestu: Yes, absolutely, WHO. You can see I'm a bit biased towards my old employer. Obviously, this is a real problem. In fact, WHO is actually calling it an "info-demic", not an epidemic. [We are] well aware of how social media in the case of COVID has been, you know, quite a big factor in spreading misinformation, creating a bit of panic, hysteria as well as spreading all this nonsense or conspiracy theories. So, what have they done?
In fact, for the last year, and this goes back before COVID, WHO had to deal with an issue around, I don't know whether you've heard of the situation, where there's been a big drop in confidence in immunisation. Anti-vaxxers spreading misinformation. So, going back to that, WHO in the last year has engaged 20 of the big technology companies. And basically, the objective is to make it harder for people to access misleading information and secondly, to remove fake content.
So, what are the examples? [On] Pinterest, if you type coronavirus now, you will be directed to a site called Mythbusters under WHO to tell you what are the facts, what are the myths. So that's Pinterest. Google has set up something called SOS alert. You click on that, it goes to the WHO data and information as well as WHO's Twitter accounts in six languages. [On] WeChat, which is the WhatsApp of China, once again, a link to the WHO Twitter account, and WHO translates that into Chinese. Most importantly, Facebook and Instagram, they've employed human fact-checkers using computer programmes to pick up any suspicious news items. And once again, they link to the WHO sites as well as the CDC, the Centre for Disease Control. And right at this moment, the Director of Digital Solutions at WHO, now that's a new position, is actually going to Silicon Valley, California to meet with this big tech company. So definitely I think they realise that, that is one approach as you say, to try and control social media, with the platforms.
The other approach is to also try the legislative regulatory process. You know, the Malaysians have actually arrested and sent to jail two or three guys who were caught spreading fake news about coronavirus. But I'm just using the WHO as one example of one attack, however, having said that, as you well know, the onus is still with Mark Zuckerberg at Facebook. Are you serious about doing this, what are you going to do, and I think some people are still skeptical whether or not he has the will to do that, but let's see.
But at least perhaps once again with a push from WHO it might happen. I'm being a little more optimistic here.
David Austin: Well great, well thank you so much. Is there anything else you want to say before we wash your hands?
Tikki Pangestu: Just one final parting point and once again, you know, in a situation like this, I think the whole world, not just Singapore, is concerned about, "What is the world doing about it?" And being at the Lee Kuan Yew School of Public Policy, especially referring to my previous Dean, Kishore Mahbubani, who is a great believer in multi-lateralism, that is the role of the international organisations in dealing with matters like this that affect all humanity. I want to say that I still believe very strongly in the value of multilateralism, in the value of the United Nations.
I believe, however, coming from a developing country there is no substitute for the UN system. You know, in terms of international solid solidarity, collectively solving problems. But as I said before, be very clear of what the UN can and cannot do, not just WHO, [which is] is part of the UN. And let me end by citing Ban Ki Moon, former secretary general, "the United Nations did not exist to take us to heaven but to prevent us from going to hell."
Photo credit: Chad Davis
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