Thank you so much.
Just echoing what Larry said, it's a real pleasure and a privilege to be speaking with you all today. I also have ties to Canada. My mother grew up in Hamilton and I still have a lot of family there in Ontario, so it's really nice to be speaking to all of you.
I have a few quick words on my background and how I come at these issues.
I come from a disaster response and humanitarian background and have worked on many health crises over the years. Most significantly, I was the head of international disaster response for the U.S. government during the Ebola outbreak in 2014 and 2015 and played a key role in leading the U.S. government's response to that outbreak.
As part of that, I became involved with WHO emergency reform and advised the then director general, Margaret Chan, on the post-Ebola reforms that were implemented. Along with Dr. Theresa Tam of Canada, I have served for the last four years on the independent oversight body that is overseeing and advising member states on the WHO's implementation of those reforms. I had a front-row seat both for the WHO's Ebola failures and shortcomings in 2014 and for their handling of this outbreak, this pandemic, and many of their other crises in-between.
To be clear, I'm speaking today in a personal capacity. I'm not speaking on behalf of the oversight committee or on behalf of WHO unless I otherwise say very explicitly.
I've been asked to speak about a few things: some of the emerging lessons from COVID-19 around the world, particularly in the developing world; WHO's effectiveness; and the support that is needed in the developing world going forward.
I would like to make first just a few observations of what, I think, we're seeing from around the world. We're seeing in many countries now that social distancing measures have worked, but they are hard to sustain. Particularly, the more drastic social distancing measures are very difficult to sustain economically, politically and socially. We're moving from a phase, I think, in which governments were largely imposing distancing measures to a phase in which we need communities and populations to voluntarily adopt distancing measures, whether governments are imposing those or not.
What we do see is that anywhere that people have let their guard down, the virus takes advantage of that. We're seeing that in real time right now in the United States. Some of the states that had not been badly affected early on dodged a bullet, concluded that they were bulletproof and began relaxing measures. Now we're seeing enormous spikes in Florida, Texas, Arizona and some of the other southern states. We're also seeing this in some of the areas of southern California where they relaxed measures too early.
I don't think we're at a point where we can go back to governments just imposing measures from the top down. They need to be adopted and owned by the population. That then becomes a matter not of governments imposing measures, but of governments communicating effectively with their people, and of public health authorities communicating effectively with their people. I think the countries that have done the best with clear communication and with building trust with their populations are the countries that have done the best and will do the best. The countries that have seen the most confusion, the most mistrust, are the countries that will do the worst.
The worst-performing countries in the world right now are the United States and Brazil, and in both of those countries, there has been horrible communication between the government and the public, a lot of confusion and a lot of mistrust.
The countries that have done the best job of communicating clearly—and I think Canada, from my observations, has done a better job of it—will do better and have done better. I will return to that point in a moment when I talk about the developing world in a bit more detail.
In terms of the WHO's effectiveness, I agree entirely with everything Larry said. Having closely observed the calamitous performance of the WHO in the early phases of the 2014 Ebola response in West Africa, I will say there's just a night and day difference between that and what they're doing now. At that time, it did not have a robust emergency capacity. Its leadership did not take the threat seriously from the beginning, and its country offices were disengaged and inattentive. There were problems at every level of the organization.
I think what we're seeing here is a very different thing. From the beginning, the organization was fully engaged. Within days of getting the formal confirmation from China of the outbreak, WHO was putting out technical guidance to all member states, at that time based largely on diseases like SARS and influenza—parallel diseases that we had seen before—because there was not much data to go on about the virus itself in those early days. That is not uncommon with a novel virus. There is always an inherent amount of uncertainty in the early phase of the emergence of a novel virus.
As Larry laid out already, there were some real challenges with China's initial reporting. I think WHO's handling of that was problematic not in terms of WHO's performance, but problematic in terms of what WHO was actually authorized to do.
The international health regulations tie the WHO's hands very tightly as to what it can say above and beyond what member states report to it. I think WHO's reporting in those early phases was.... If you read between the lines a bit, it was definitely hedging because it knew that what it was getting from China might not be the full picture.
As that picture fleshed out, within about three weeks from the confirmation from China, the WHO's country office in China was authorized to do a mission to Wuhan and and an on-the-ground investigation. Immediately after that, which was on January 20 and 21, the WHO came out and confirmed human-to-human transmission. Within another day or two, it convened the emergency committee to review whether to declare it a public health emergency of international concern.
At that time, the WHO confirmed a basic picture of the virus that still holds up pretty well today: It is a novel respiratory coronavirus that is transmitting efficiently from human to human; it has a reproduction number, or a transmissibility factor, that is higher than the seasonal flu; and it has a severity and death rate that are absolutely multiples higher than the seasonal flu. This initial picture of the virus is an extraordinarily scary picture.
Within another week of that meeting, the WHO took the step of declaring a public health emergency of international concern, which is the highest level of alert that member states have created for the WHO under the international health regulations. At that point, the WHO rung the loudest alarm bell it had available to it and provided a picture of the virus that holds up pretty well today.
This should have been very alarming, but what we saw was a huge amount of variance in how states reacted to that. Some countries, particularly the East Asian countries that had prior experience with SARS, took it extraordinarily seriously and began immediately implementing very drastic measures. South Korea, Taiwan, Hong Kong, Japan, Thailand and Vietnam all clamped down very quickly and began scaling up their testing, implementing distancing measures and so on. Western Europe and most of the Americas did not. You had different countries looking at the same information from the WHO and doing very different things.
I think that is more reflective of those countries than it's reflective of the WHO, but I think it also reflects something else. In a report that the committee I serve on published last month, we highlighted a few emerging takeaways from that period. One is that it's important to distinguish between where the failures were and where the weaknesses were. What were the things that the WHO, as a secretariat and institution, did poorly? There are some, but I think broadly they handled it well. What failings were due to countries' reactions to the information the WHO was providing? I think many countries were far too cavalier in assuming that this would be a problem in China and would not affect them. What problems rest within the international health regulations? For which problems was the WHO's ability to do more or ability to be louder and more forthright limited or inhibited by the restrictions member states have created within the international health regulations? I can go into more detail on that, but I agree with some of Larry's points on this from earlier.
In the committee report, we also noted that the public health emergency of international concern, this alarm bell that the WHO can bring, is far too blunt a tool. It is a binary, on or off. It does not have any gradations within it. It is declared for something like this, a world-threatening pandemic that could potentially kill millions of people. It's also declared for something like the Ebola outbreak that has been going on in eastern Congo for the past two years, which has killed 2,000 people and has not really gone beyond that subregion of Africa.
There's a huge range of health crises that are included in that kind of a tool. We need more gradations so that countries can read those signals a bit more clearly to know what the level of threat is to them when a declaration of emergency is made.
We also found that the post-Ebola reforms have been effective, even though they were premised on a different sort of crisis. They were premised on the Ebola crisis in 2014 and the range of humanitarian emergencies that the WHO normally contends with, and something on this scale has hugely strained the bandwidth and capacity of the WHO. The WHO has not always done as good a job with managing some of the capacity trade-offs there as we would like to see, particularly when it comes to keeping an updated set of technical guidance and recommendations for countries. That's the last point I want to make there.
To pivot to the question of lower- and middle-income counties, I think the WHO and institutions like the CDC in the U.S. have been too slow to adapt the strategy and guidance that has been developed largely for rich countries to lower-income settings. One of the interesting characteristics of how this outbreak has played out is that it predominantly affected wealthy countries at first. China is a wealthy country with a very developed health system. Then it hit Italy and hit Spain and then the United States. All of these countries have a high capacity for clinical treatment, have a lot of resources to scale up testing and have a lot of resources to sustain large-scale social distancing and lockdown measures.
Few of those things are true in the developing world. The WHO, along with the rest of the UN system, did put out very good guidance on this in mid-May. It should have come out earlier, and that's partly a capacity issue within WHO. That left a lot of lower-income countries struggling to figure out the strategy they should apply, because scaling up ventilators, mass testing and PPE production was not something that was really available for them to do financially. The ability to sustain a lockdown when you have a large informal economy or a large grey economy is also very difficult.
One other point I would make about lower and middle-income countries is that there is very little money getting to front-line and local organizations in those countries. I published a piece this week that looked at the humanitarian aid flows that have gone for COVID, which amount to about $2.5 billion now in response to the global humanitarian COVID appeals. Of that, less than $2 million out of $2.5 billion is reported as having gone directly to local front-line organizations.
That's a recipe for failure, because, as I said, we're at a point now where we need to transition this response from something that is government owned to something that is community owned and led. If more than 99% of the money is going to international organizations and international partners, and the local community and local groups are getting only the scraps of the scraps of the scraps, it's going to be hard.
I'll stop there.
I look forward to your questions.