The year 2020 has been like no other in our lifetime, and I was tempted to give my end of year award to the coronavirus COV-SARS-2 and the new way of living and dying it spawned. But this award looks for human agency and no-one has had a more difficult task with the pandemic than the World Health Organisation and its Ethiopian director-general Dr Tedros Adhanom Ghebreyesus. Tedros and the WHO have faced unimaginable challenges with an inescapable political element hampered by a secretive China and an incompetent US president. But the organisation and its leader are the reason the 75 million cases and 1.7 million worldwide death toll have not been much higher as vaccines emerge in 2021.
When on December 31, 2019 people were wishing Dr Tedros a happy new year, he must felt uneasy. That day his organisation got the disquieting message of cases of pneumonia “of unknown etiology” (cause) in China. This was potentially the worst-case scenario Tedros was preparing for all his life. Tedros is not a medical doctor but got his doctorate in community health from the University of Nottingham for his 1990 research which found a sevenfold increase in malaria near dams in his home Tigray region.
When Tedros joined the Ethiopian health department in 1986 Tigray (now sadly embroiled in war once more) had just emerged from a devastating famine. His work led to a 20% reduction in AIDS and 70% reduction in malaria cases in that region. Visionary prime minister Meles Zenawi appointed Tedros health minister in 2005 when there were more Ethiopian doctors in Chicago than in Ethiopia. Tedros managed to reduce malaria by half in two years and he was appointed foreign minister in 2012.
In 2017 he was named the first African director of WHO with a priority of “health for all”. While there was opposition to his candidacy, with issues such as Ethiopian enabling of the nicotine industry, many saw his appointment as a turning point for the WHO. Throughout his career Tedros has stood for equity and access, as Time puts it, “the idea that all people, wherever they are and whatever their circumstances, have the right to quality health care”. Growing up he saw how preventable diseases took the lives of children including his younger brother. His experience in the DRC Ebola outbreak taught him unless the most vulnerable are not protected from infectious disease, none are protected.
The idea for a world health body is 200 years old. Increased international trade and travel in the 19th century led to global health catastrophes and cholera epidemics in 1830 and 1847 killed tens of thousands. The first International Sanitary Conference convened in Paris in 1851, the first attempt at international cooperation for disease prevention and control, though the cause of cholera remained unknown and political differences meant little was accomplished. In 1892 an International Sanitary Convention for cholera control was adopted and five years later a Convention addressed control of the plague. In 1919 the League of Nations established a Health Organisation and it was recognised again after World War II. In 1948, the WHO Constitution obtained enough signatures to bring it into force, strongly backed by the Americans who remain the top donor.
The WHO backed programs to eradicate smallpox, polio, AIDS, Ebola and others. But its biggest fear was dealing with an influenza pandemic, recognised since the 1918 flu pandemic killed 500 million people. The world dodged bullets in recent times with SARS, swine flu and then MERS and on the 100th anniversary of the flu pandemic in 2018, the WHO warned urbanisation, mass migration, global transport and trade, and overcrowding accelerated virus spreads “which ignore national borders, social class, economic status, and age.”
The WHO activated its Global Influenza Strategy after his China Country Office heard of cases of pneumonia of unknown cause in Wuhan on December 31, 2019. On January 1, WHO created an Incident Management Support Team which requested further information to assess the risk and by January 3, 44 patients were reported, 11 severely ill. China closed the Wuhan wet market for sanitation and disinfection.
On January 5, WHO notified member states about the new outbreak and on January 10 offered a “comprehensive package of guidance” for countries on how to detect and test potential cases warning of the risk of human-to-human transmission. US president Donald Trump later lied the WHO did not do so until April. Trump relied on a January 14 WHO tweet which reported “preliminary investigations conducted by the Chinese authorities have found no clear evidence of human-to-human transmission” but WHO was already warning health leaders to look for signs of transmission, and to take precautions as if it was happening.
The mystery illness was given a name, novel coronavirus, after China shared its genetic sequence and “coronavirus” quickly became a household name though SARS-1 was also a coronavirus. On January 13 Thailand confirmed the first case outside China with a 61-year-old Wuhan tourist recovering in hospital. By January 20 the WHO confirmed there was human-to-human transmission in Wuhan.
On January 22 Tedros convened an emergency committee to assess whether the outbreak constituted a public health emergency of international concern. The virus had spread to Japan, South Korea, and the US. In China 17 people had died and authorities shut down transport around Wuhan quarantining 20 million people. The committee could not reach a consensus. Tedros said more information was required. “Make no mistake: This is an emergency in China,” he said. “But it has not yet become a global health emergency. It may yet become one.”
Within days the WHO’s updated situation report said the risk was “very high in China, high at the regional level and high at the global level”. In a footnote, they admitted an error in previous communications which said the global risk was moderate. By January 30 Tedros said the fast-spreading strain was a global health emergency. “This vote is not a declaration of no confidence in China,” he said. “The WHO is concerned about what will happen if the virus spreads in countries with weak health systems and declaration is to help those countries.” The number of deaths rose to 213, all in China. Four days later it was 361 and many countries imposed Chinese travel bans. There was also the first death overseas in the Philippines but after meeting Chinese president Xi Jinping Tedros was not ready for measures that “unnecessarily interfere with international travel and trade”.
The WHO held a 300-scientist forum in mid February to set global research priorities into the newly named COVID-19 disease. “Equitable access – making sure we share data and reach those most in need, in particular in lower and middle-income countries, is fundamental to this work which must be guided by ethical considerations,” the chair of the forum said.
The WHO–China Joint Mission issued a report about the evolution of the outbreak. As of 20 February, 75,465 COVID-19 cases were reported in China and transmission was largely occurring in families. Most had mild symptoms and recovered but those over 60 with comorbidities were vulnerable. Bats appeared to be the virus reservoir, but intermediate host(s) had not been identified. It was transmitted “via droplets and fomites during close unprotected contact between an infector and infectee” with no pre-existing immunity in humans. Three-quarters of victims were in Wuhan and although it was a massive Chinese travel hub the cordon sanitaire imposed on January 23 had largely protected the rest of the country. Jinping put control of the outbreak as the government’s top priority and deployed 40,000 health care workers to support the Wuhan response. China applied big data and artificial intelligence to strengthen contact tracing and the management of priority populations.
The mission concluded China had “rolled out perhaps the most ambitious, agile and aggressive disease containment effort in history” helped by “a deep commitment of the Chinese people to collective action in the face of this common threat.” Case numbers were declining but every Chinese province and city was “urgently escalating acute care beds and public health capacity”. It urged reassessment of restrictions on Chinese travel. However the disease was highly contagious, and the rest of the world was not as prepared as China.
March 3 was Tedros’s 55th birthday and the world was glued to his daily media conference on the growing threat. There were 3000 fatalities mostly in China but 61 other countries reported 8739 cases with 127 deaths. Tedros noted nine times more infections outside China than inside. “The epidemic in Korea, Italy and Iran and Japan are our greatest concern”, he said. Korea had half the total but good contact tracing was keeping it under control. “Understanding your epidemic is the first step to defeating it,” he said. The cost of surgical masks rose 600pc, and the price of gowns doubled amid widespread manipulation and new stocks going to the highest bidder.
On March 7 worldwide cases topped 100,000, a “sombre moment” said Tedros. Four days later stock markets plunged as he officially declared it a pandemic – the first caused by a coronavirus – with 118,000 cases in 114 countries, and 4291 deaths. The world was shocked as Italy went into national lockdown. The number of cases outside China had increased 13-fold in two weeks but with 90pc in just four countries (China, Korea, Iran and Italy) Tedros stressed it could be defeated. “If countries detect, test, treat, isolate, trace, and mobilise their people, those with a handful of cases can prevent those cases becoming clusters, and those clusters becoming community transmission,” he said.
There were new guidelines for personal behaviour such as social distancing, regular handwashing and coughing into your elbow. Tedros warned this was not enough to extinguish the pandemic and governments needed to step up to “isolate, test, treat and trace”. “You cannot fight a fire blindfolded” he said. He recommended testing every case. “We cannot stop this pandemic if we don’t know who is infected”.
By March 18 WHO announced its first vaccine trial as cases exceeded 200,000 and 8000 deaths. Argentina, Bahrain, Canada, France, Iran, Norway, South Africa, Spain, Switzerland and Thailand confirmed their participation in the Solidarity Trial. “This large study is designed to generate the robust data we need to show which treatments are the most effective”, Tedros said. China had almost defeated the virus with no cases for the first time since December but the virus was increasing elsewhere at an alarming rate. It took three months to reach the first 100,000 cases but only 12 days to double that.
In April many countries followed Italy into lockdown and the WHO reported deaths had doubled in the previous week and would soon reach 50,000 globally, with the caseload heading towards one million. Tedros addressed the debate over masks. “WHO recommends the use of medical masks for sick people and those caring for them”, he said. “However, in these circumstances, masks are only effective when combined with other protective measures”.
US hospitals were not ready. PPE was in short supply, there was limited testing and Trump was downplaying the crisis. On April 8 Trump blamed the WHO for America’s poor response to the “Chinese virus” and warned he would stop funding it. Trump said the WHO had not supported his January 31 decision to limit travel from China. The WHO said restricting the movement of people and goods during public health emergencies was “ineffective in most situations and may divert resources from other interventions.” The New York Times wrote Trump blamed the WHO for his own failures. “Public health experts said the president’s public denials of the virus’s dangers slowed the American response, which included delayed testing and a failure to stockpile protective gear,” it wrote.
While Australia questioned Trump’s claim the virus came from a Wuhan lab, it sponsored a motion with the EU at the World Health Assembly to establish an independent review of the virus, coordinated by the WHO. China opposed Australia’s calls, but ended up co-sponsoring the motion saying it was vastly different to Australia’s position. Australia strengthened the EU’s original motion to explicitly state the review should be “impartial, independent and comprehensive”, a move that led to massive revenge Chinese trade sanctions on Australia later in the year.
Tedros insisted the focus should be on fighting the virus. He said the US and USSR co-operated in the Cold War to eradicate smallpox. “Now the US and China should come together and fight this dangerous enemy,” he said. Tedros outlined five reasons why the WHO was needed: helping countries to prepare and respond, providing accurate information and busting dangerous myths, ensuring vital supplies reach health workers, training and mobilising health workers, and leading the vaccine search.
By mid April the WHO said COVID-19 was 10 times deadlier than the 2009 flu pandemic and in some countries the number of cases was doubling every 3-4 days. It stressed early case-finding, testing, isolation and care, and contact tracing to stop transmission. Before lifting lockdowns countries needed to control transmission, ensure the health system tracked every case has been controlled, put in preventative measures and educate communities about the “new norm”. Many countries ignored this advice leading to second and third waves. At the end of the month Tedros convened an emergency committee meeting which agreed the pandemic still constituted a PHEIC. In April, 80,000 cases were reported each day. Cases topped three million globally, with 224,000 deaths.
On May 11 Tedros warned cases were surging again in Korea, China and Germany following the lifting of stay-at-home restrictions. While lockdowns slowed transmission and saved lives, Tedros acknowledged a serious socio-economic impact. “To protect lives and livelihoods, a slow, steady, lifting of lockdowns is key to stimulating economies, while also keeping a vigilant eye on the virus so control measures can be quickly implemented if an upswing in cases is identified”, he said.
The virus was hitting hard in Central and South America due to dense population and urban poverty. Five of the 10 countries with the highest number of COVID-19 cases at the start of June were Brazil, US, Peru, Chile and Mexico. Cases topped 200,000 in Africa by the middle of June. The WHO advised people to wear masks in public but said masks alone would not beat the virus. On June 18, 150,000 new cases were reported, the highest single daily total yet. Most were in the Americas, though large numbers came from South Asia and the Middle East. Tedros said the world was in a new and dangerous phase. “Many people are understandably fed up with being at home. Countries are eager to open up their societies and economies”, he said. “But the virus is still spreading fast, it’s still deadly, and most people are still susceptible.”
That number was beaten four days later with 183,000 new infections in 24 hours, bringing the total to 8.8 million cases worldwide, and 465,000 deaths. Tedros urged fundamental public health measures to limit spread: finding and testing suspected cases, isolating and caring for the sick, tracing and quarantining contacts, and protecting health workers.
Into July the numbers climbed steeply. Cases doubled in six weeks reaching 12 million by July 10. It soared to 16 million cases and 640,000 deaths by month end, six months since the PHEIC was declared. In August Tedros brought the sobering news there was “no silver bullet and might never be”. The WHO noted the virus was disrupting services on other diseases, compounding reduced immunisation coverage, cancer screening and care, and mental health services while COVID-19 was also causing immense social, economic and political damage.
By end August the pandemic was eight months old. India reported 78,000 new COVID-19 cases, surpassing the US record two days straight. Tedros warned countries reopening economies to do so safely. “Opening up without control, is a recipe for disaster,” he said. “While this may seem an impossible balance, it can be done if countries are in control of transmission.” Many countries did not heed the advice leading to second and third waves.
By September 7 Tedros was looking to the future – and the next pandemic. He reminded the world health was not a luxury item for those who can afford it. “It’s a necessity, and a human right. Public health is the foundation of social, economic and political stability,” he said, calling on countries to invest in services to prevent, detect and respond to diseases. “Part of every country’s commitment to build back better must be to invest in public health, as an investment in a healthier and safer future. We are not just fighting a virus. We’re fighting for a healthier, safer, cleaner and more sustainable future.”
On September 28 global COVID-19 deaths passed one million. A few days later headlines were dominated Donald and Melania Trump contracting the disease, among the two million cases that week. When asked if Trump’s disregard for mask-wearing made it inevitable that he would contract COVID-19, WHO’s Irish Emergencies Executive Director Dr Mike Ryan wouldn’t comment on the risk management measures of any individual.“What we will reiterate, is that each and every individual and each and every citizen should be guided by the national guidance in their country.”
As the WHO estimated 10pc of the world’s population was infected, Tedros rejected herd immunity as “scientifically and ethically problematic”. “Never in the history of public health has herd immunity been used as a strategy for responding to an outbreak,” he said. To obtain herd immunity from measles 95pc of the population must be vaccinated. However 90pc of the world remained susceptible to COVID and cases were rising again in the US and Europe. “Letting the virus circulate unchecked, means allowing unnecessary infections,” he said.
By October 15 Europe recorded seven million cases of COVID-19, jumping from six million in 10 days. Though the peak was twice as high as April , there were five times fewer deaths. That meant more younger people were contracting the virus. The emergency committee held its fifth meeting at end October where the global risk level remained “very high” and the PHEIC was retained until 2021. Global cases reached 44 million, with over 1.1 million dead.
While coordinating the virus response, the WHO has also been at the forefront of vaccine research. They were part of a multinational collaboration, with the Coalition for Epidemic Preparedness Innovations, GAVI (Vaccine Alliance), the Gates Foundation, and governments which formed the Access to COVID-19 Tools (ACT) Accelerator, to fund accelerated research and development, production, and globally-equitable access to COVID-19 tests, therapies, and licensing of vaccines in a “COVAX Pillar” program. The Pillar’s goals were to help license vaccines, influence equitable pricing, and provide equal access for two billion doses by end 2021 to protect healthcare workers and high risk people in low-to-middle income countries.
While the figures remain grim at the end of the year, attention is turning to the vaccines rollout in 2021. Tedros hailed the scientific community for setting “a new standard for vaccine development” and now the international community must set “a new standard for access”. “The urgency which vaccines have been developed must be matched by the same urgency to distribute them fairly”, he said warning of a risk the poorest will be “trampled in the stampede” to get innoculated. Five vaccines are approved at the time of writing (BBIBP-CorV and CoronaVac in China, Gam-COVID-Vac in Russia, Moderna in the US and Pfizer’s Tozinameran the most widespread in several countries including the US, Canada and the UK).
COVID-19 is not the only WHO’s health crisis and Joe Biden’s presidential win means the US will continue to fund their vital work. But no WHO leader has ever had to deal with anything on the scale of COVID-19. Tedros was not faultless but he has steered a difficult diplomatic and medial course with honour and courage keeping the world informed honestly all the way. Tedros says his focus remains on the COVID-19 “end game” — ensuring all countries enjoy the same access to vaccines. He is a deserving recipient of my media person of the year 2020.