TORONTO – Would you choose the word “emergency” to describe a disease that has sickened 82 people in eight countries over the last 16 months? Would your thinking change if you knew it had killed 45 of those people? What about if you knew the virus that caused the disease is related to the one that caused SARS?
Despite the high death rate and SARS connection, it’s hard to imagine many lay people would currently see the slow-but-steady MERS coronavirus outbreak as an emergency. And yet a panel of international experts — known as the Emergency Committee — is being asked whether they think the disease event meets that definition when they gather by teleconference Wednesday to assess the threat posed by the Middle Eastern respiratory syndrome virus.
The experts, pulled together by the World Health Organization under powers given it by the International Health Regulations (the IHR), are expected to advise WHO Director General Dr. Margaret Chan on Wednesday whether she should declare MERS a “public health emergency of international concern” or PHEIC, in the jargon of the WHO. Chan doesn’t have to take the advice, but it’s hard to see why she would reject the guidance after asking for it.
Emergency Committee. Public Health Emergency of International Concern. These terms come directly from the IHR. And they present the WHO with significant communications challenges as they figure out what to do about MERS, experts acknowledge.
“Everybody thinks of an ‘emergency’ as something that’s already imminent, something that requires people to drop what they’re doing and take urgent action now. By that standard, MERS obviously isn’t an emergency,” says Peter Sandman, a risk communications guru who is based in New York City.
“What worries WHO and other public health agencies is the risk that it could become an emergency with very little warning.”
When WHO assistant director general Dr. Keiji Fukuda announced that WHO was convening an emergency committee to study MERS earlier this month, he explained that the agency wasn’t trying to convey that the world was on the verge of a global outbreak of MERS. Rather, he said, the WHO is concerned about the new virus and wants help assessing the risk it poses.
If the WHO declares MERS a public health emergency of international concern, it would add weight to its calls for quick and full reporting of all cases and to its recommendations to countries to be on the lookout for MERS cases.
Under the IHR, the declaration of a PHEIC could also be accompanied with recommendations to restrict travel. But urging Muslim pilgrims not to travel to Saudi Arabia — the seat of their religion, but also the site of most MERS cases — does not appear to be a step the WHO is currently considering.
Sandman, who has advised many high-profile public institutions as well as corporate clients, says it is unfortunate that the IHR doesn’t use less loaded language, suggesting something like a “threat assessment committee” and a “public health threat of international concern” would convey more accurately the situation the WHO currently finds itself in.
Whatever the committee recommends — and whatever Chan decides to do with that recommendation — the WHO should address the language problem head on, he says, suggesting the organization cast it something like this:
“It’s really a committee to advise us on whether we should ask the world to start preparing for a possible emergency. And what IHR calls a ‘Public Health Emergency of International Concern’ is really a public health threat — a possible emergency — of international concern,” he said in an interview that was part phone conversation, part email exchange.
“A PHEIC declaration is a wake-up call, not an ambulance siren.”
Infectious diseases expert Michael Osterholm also rues the language, though he applauds the WHO’s decision to seek expert guidance on this issue at this time.
The world will be better prepared to cope with MERS as a result of the WHO’s action if the virus does start spreading more widely, says Osterholm, the director of the Center for Infectious Diseases Research and Policy at the University of Minnesota.
“We need a new vocabulary,” he says, but adds that he thinks it is justifiable to declare the MERS outbreak a public health emergency of international concern, given that is the term currently available for use.
Osterholm says the WHO finds itself in a situation commonly experienced by national weather services. They are hammered if they warn about storms or tornadoes that don’t materialize, but are also lambasted if they don’t warn enough about an event that turns out to cause significant damage.
“Like that tornado, it (a global MERS outbreak) may never happen. (But) it could happen tomorrow. It could happen this afternoon. And I think there’s clearly enough data to support that,” Osterholm says.
Many mysteries remain about MERS, making it hard for public health experts to gauge the risk it poses. The source of the virus, which was first identified in June 2012, has still not been identified. Nor is it yet known how people are becoming infected — and how, by extension, to stop that process.
So far all cases trace back to four Middle Eastern countries — Saudi Arabia, Qatar, Jordan and the United Arab Emirates. But whether those are the only countries in which infections are occurring is unclear. It’s not certain surveillance in the region is strong enough to say with certainly that infections are not occurring elsewhere.
And a potential downside of declaring MERS a public health emergency at this stage is that new countries might actually be reluctant to come forward and declare cases, says David Fidler, a professor of international law at the University of Indiana.
That’s because even if the WHO doesn’t recommend world travellers avoid MERS-affected countries, other countries may move to impose sanctions or restrictions of their own once a PHEIC is declared, Fidler says.
The International Health Regulations — which are not binding — say countries shouldn’t take actions that restrict international travel. But experience with the 2009 H1N1 flu pandemic showed that some countries took actions the WHO had explicitly advised against, he notes.
“The power to declare a PHEIC carries with it serious political and economic consequences that could complicate international co-operation on bringing the threat under control,” says Fidler.
“A PHEIC declaration might deter countries from reporting new cases, especially if, out of the gate, countries begin imposing on Saudi Arabia measures that damage it politically and economically for reasons not justifiable on public health and scientific grounds.”