Diagnostics and Diplomacy
It is a well-worn trope that diseases know no borders; nor are they particularly sensitive to timing. Any day now, the number of reported cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) — a novel infectious disease that emerged in the midst of a region struggling to achieve a new equilibrium — is expected to top one hundred. Just how large and how quickly that number will grow remains the subject of intense scrutiny.
MERS-CoV presents a serious challenge. Yet, compared to just ten years ago, the global community is far better equipped to handle it. And while medical technology has advanced rapidly, it is a centuries-old too–diplomacy–that is helping to get the right information to the people capable of limiting the outbreak.
Sounding the Alarm
Today, many details about the source and spread of the virus remain unclear. So far, nine countries have reported cases of MERS-CoV since 2012. Saudi Arabia, the first country to report the emergence of the novel coronavirus, accounts for three-quarters of these cases. Most of the deaths have occurred in people with serious underlying medical conditions, such as heart disease or cancers, and the virus appears to spread only through close contact. However, the high fatality rate (more than half of confirmed cases have died) and transmission of the virus between infected patients and healthcare workers have raised alarms.
Concerns have only grown as the annual Hajj pilgrimage approaches in October. In a typical year, about 3 million Muslims from around the world travel to the Saudi Arabian city of Mecca for the annual Hajj pilgrimage, one of the largest mass gatherings in the world. The Umrah pilgrimage can be made at any time, but many Muslims plan their travel to Mecca during the month of Ramadan (ending in early August this year).
Tapping into Diplomacy
Although the outcomes remain to be seen, what is unquestionable is how much has changed since the related SARS coronavirus emerged ten years ago. The SARS outbreak simmered quietly in China before international travelers dramatically spread the virus to countries around the world, infecting about 8,000 people and killing almost 800 in a matter of months. China’s initial lack of transparency complicated the investigation and management of the outbreak. Diplomatically complicated relationships between China, other governments, and international organizations offered neither a framework for the technical exchange of information nor a platform for constructive engagement.
In addition to lives, the SARS outbreak cost affected regions tens of billions of dollars. The political and economic impact inspired China to strengthen its domestic capacities and to explore new engagements in global health. The SARS outbreak also catalyzed a new approach to international public health cooperation. WHO’s Member States agreed in 2005 to revise the International Health Regulations (IHR). This binding agreement dramatically overhauled the global governance of disease detection and response, providing a framework for WHO to coordinate the response to emerging public health threats and requiring nations to achieve basic core capacities for disease detection and response.
Ten years later, China is once again dealing with an emerging infectious disease (a new strain of influenza). This time, China reached out to WHO and to the United States Centers for Disease Control and Prevention, which spent the past decade working with China to build a strong platform for coordination and collaboration on technical health issues. China engaged these partners in assessing the risk that this new influenza strain poses to populations within and beyond its borders, and is using this knowledge to develop new tools to track and contain the outbreak.
There have also been hiccups in information-sharing among some countries affected by MERS-CoV as scientists wrestle with concerns about who owns and uses such knowledge. However, ten years after SARS shook the status quo, early communication on outbreaks through bilateral and multilateral channels has become the expectation rather than the exception. In 2003, faced with China’s taciturn silence, WHO advised governments of the spreading SARS epidemic through improvised public warnings. The mystery shrouding the outbreak’s origins helped fuel international fears and the backlash that decimated trade and travel throughout East Asia. In 2013, under the revised International Health Regulations, WHO has been able to issue updates and evidence-based recommendations to governments and healthcare providers, helping countries detect and respond to MERS-CoV infections among travelers without resorting to unhelpful and economically damaging actions.
The Saudi Arabian Ministry of Health has not only notified cases to WHO but has reached out to the international public through electronic and traditional media, recommending that people with underlying health conditions that might put them at increased risk of getting sick postpone any plans for Hajj or Umrah pilgrimages this year. Other countries in the region, in addition to reporting cases to WHO, have participated in training for laboratory detection supported by WHO and U.S. government expertise and resources. The International Health Regulations strengthened WHO’s authorities for two-way communications with health authorities, helping to facilitate capacity-building and information exchange even where governments are in flux. The global community now has a platform for technical cooperation that doesn’t need to await a diplomatic process. Most importantly, we don’t need to wait for a global crisis to start to develop technical tools and knowledge to mitigate the consequences of an emerging health threat.
In July 2013, the World Health Organization’s Director-General convened technical experts from various fields and countries to evaluate the unfolding MERS-CoV situation, as per the International Health Regulations. Based on their advice, the Director-General decided not to declare MERS-CoV a public health emergency of international concern at this time, but the committee identified opportunities to strengthen global vigilance. Saudi Arabia has stepped up precautions to prevent outbreaks among Umrah and Hajj pilgrims even as WHO issued guidance to help governments plan for, detect, and manage any cases of MERS-CoV illness among returning travelers.
While not a seamless safety net (thousands of pilgrims will still return to countries with limited capabilities for response), the progress made in the last ten years in global health diplomacy is now paying off. As an added bonus, the technical relationships forged can also strengthen diplomatic relationships, as governmental experts quietly negotiate dozens of details every day in the laboratory, in the field, and at the planning table, building transparency and mutual trust.
Diplomacy doesn’t stop outbreaks. But the new framework for international health cooperation means that experts can work together across borders with unprecedented speed to identify and respond to outbreaks before they spread worldwide.
Julie Fischer, PhD is an Associate Research Professor in the Department of Health Policy at George Washington University. Rebecca Katz, PhD MPH is an Associate Professor of Health Policy and Emergency Medicine at George Washington University, as well as a Fellow at the Truman National Security Project. Together they direct a portfolio of research projects in global health security.