Sunday, 19 April 2020

FactChecking Trump’s Attack on the WHO

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In announcing that his administration would halt funding for the World Health Organization, President Donald Trump made a series of false, misleading and unsubstantiated claims about the WHO:
  • Trump inaccurately said the WHO stated that the novel coronavirus “was not communicable.” The agency never went that far. In mid-January, the WHO shared “preliminary” information from China that “found no clear evidence” of human-to-human transfer, but it continued to consider such transmission possible.
  • The president also claimed there was “credible information” to suspect human-to-human transmission in December 2019. The WHO wasn’t notified of an outbreak in Wuhan until Dec. 31.
  • The president said the WHO “took China’s assurances” about the coronavirus “at face value … even praising China for its so-called transparency.” But early on Trump also thanked China for “their efforts and transparency,” and said he trusted that China would provide the U.S. with all of the necessary information.
  • Trump exaggerated when he said the WHO “actually fought” the U.S. over his decision to impose travel restrictions on China. WHO leaders have not publicly criticized the U.S. for that decision, although they did, and continue to, advise countries not to enact travel restrictions in reaction to the spread of the coronavirus.
  • Research has shown travel restrictions can delay the exportation of viruses, but they can’t contain the spread. But Trump repeated his claim, without evidence, that if he hadn’t put restrictions on travel from China, “probably hundreds of thousands more” would have died.
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Trump made his announcement on funding at the White House coronavirus task force daily briefing on April 14, accusing the WHO of “severely mismanaging and covering up the spread of the coronavirus.” There is no evidence that the WHO has covered up the spread of the novel coronavirus. There has, however, been evidence that China was slow to report the outbreak.
The South China Morning Post reported that the first coronavirus case in China can be traced back to Nov. 17, although China did not report it as a novel disease to the WHO until Dec. 31.
Trump’s announcement has been criticized by health experts and organizations, including the American Medical Association, which called it a “dangerous step” at a time when the pandemic worldwide has cost the lives of more than 130,000 people and counting. The U.S. provided more than $400 million to the WHO in 2019 — the most of any nation, according to the State Department.
House Speaker Nancy Pelosi called the withholding of funds illegal and promised to challenge it.
WHO: Broad Mandate, Limited Powers
The World Health Organization, established in 1948 as part of the United Nations, has a broad role in coordinating international health policy. But while its mandate is large, its powers are limited.
Based in Geneva, Switzerland, and with six regional offices as well as representatives in countries around the world, the WHO is run by the World Health Assembly, made up of representatives of the WHO’s 194 member nations. Its director-general is Dr. Tedros Adhanom Ghebreyesus, a former minister of foreign affairs and minister of health in Ethiopia, who was elected to a five-year term in 2017.
The WHO has had some important achievements over the years, including its role in eradicating smallpox in 1979. But it was heavily criticized for its slow response to the 2014 Ebola outbreak. (See the Council on Foreign Relations’ website for a backgrounder on the WHO.)
The WHO, which has no direct authority over its 194 member states, describes as its key functions, among other things, “shaping the research agenda,” “providing leadership” on critical health issues, “setting norms and standards,” and monitoring and assessing health trends.
One of its vital roles stems from its exclusive authority to declare a public health emergency of international concern, or PHEIC. Since it received that power in 2007, it has done so six times, most recently during the current novel coronavirus pandemic. During such emergencies the WHO can issue guidelines on how countries should respond, including with travel and trade restrictions. But the guidelines are nonbinding; the organization has no enforcement powers.
In a recent report, the nonpartisan Congressional Research Service explained the process for declaring public health emergencies:
CRS, March 16: Following the emergence of a disease that might be deemed a PHEIC, WHO convenes an advisory group, known as the IHR Emergency Committee, which reviews data to make recommendations to the WHO Director-General on control measures for the disease and whether to declare a PHEIC. The composition of this group varies per outbreak. The IHR Emergency Committee for Pneumonia Due to the Novel Coronavirus 2019-nCoV, for example, is comprised of 15 scientists from around the world, including Dr. Martin Cetron from the U.S. Centers for Disease Control and Prevention (CDC). The WHO Director-General usually follows the advice of IHR emergency committees regarding PHEIC declarations.
Although Trump accused the WHO of failing to provide “accurate information” in a “timely manner,” the organization is dependent on its members to report health crises. And historically some nations have been reluctant to do so in a timely manner. That was the case with China and SARS in 2003. And that has been an issue during the coronavirus pandemic, as China has been criticized for failing to be fully transparent about the disease, which originated there late last year.
Distortions on Transmissibility
One of Trump’s key claims is that the WHO misled the world about the virus’ ability to spread from person to person.
Trump, April 14: The WHO failed to investigate credible reports from sources in Wuhan that conflicted directly with the Chinese government’s official accounts. There was credible information to suspect human-to-human transmission in December 2019, which should have spurred the WHO to investigate, and investigate immediately. Through the middle of January, it parroted and publicly endorsed the idea that there was not human-to-human transmission happening despite reports and clear evidence to the contrary.
Trump later stated that the WHO said the virus “was not communicable.” 
While there is a debate about what was known when — and it seems clear that China knew more than what it reported — the WHO never said the virus was not communicable. Instead, the agency always considered the possibility, even if it also shared information from China that found no evidence of such transmission.
Trump’s mention of mid-January is likely a reference to an early morning Jan. 14 tweet from the WHO. “Preliminary investigations conducted by the Chinese authorities,” it said, “have found no clear evidence of human-to-human transmission of the novel #coronavirus (2019-nCoV) identified in #Wuhan, #China.”
Lack of evidence, especially of “preliminary” results, does not mean the WHO was saying the novel coronavirus could not be spread between people.
The same day as the tweet, the WHO cautioned that there might be some human-to-human transmission of the virus among family members in China.
“From the information that we have it is possible that there is limited human-to-human transmission, potentially among families,” said Maria Van Kerkhove, the acting head of WHO’s emerging diseases unit, in a Jan. 14 news briefing. “But it is very clear right now that we have no sustained human-to-human transmission.”
According to a timeline of events, Van Kerkhove, who is also the WHO’s technical lead for the COVID-19 response, also said that human-to-human transmission wouldn’t be unexpected, since that is what occurs with SARS and MERS, which are also coronaviruses.
Knowledge about those other viruses was also the basis for the WHO to recommend in its Jan. 10 technical guidance that health workers take precautions to avoid transfer of the virus from patients.
The day before, the WHO did report information it received from China about the virus, saying in a Jan. 9 statement, “According to Chinese authorities, the virus in question can cause severe illness in some patients and does not transmit readily between people.” But the organization also said “more comprehensive information is required to understand the current status and epidemiology of the outbreak,” and that “[f]urther investigations” were also needed to determine “modes of transmission.”
By Jan. 19, the WHO was more definitive, saying in a tweet that there was “some limited human-to-human transmission occurring between close contacts.” 
And on Jan. 20, the WHO’s Western Pacific Region iterated the point. “It is now very clear from the latest information that there is at least some human-to-human transmission of #nCoV2019,” a tweet explained. “Infections among health care workers strengthen the evidence for this.”
A follow-up tweet also indicated the possibility of viral transmission that continues, rather than dying out in a small group of people. “In addition, info about newly reported #nCoV2019 infections suggests there may now be sustained human-to-human transmission,” the WHO’s Western Pacific Region said. “But more information and analysis are needed on this new virus to understand the full extent of human-to-human transmission and other important details.”
After a WHO delegation visited Wuhan on Jan. 20 and 21, the organization also issued a statement, saying that “[d]ata collected through detailed epidemiological investigation and through the deployment of the new test kit nationally suggests that human-to-human transmission is taking place in Wuhan.”
China publicly confirmed human-to-human transmission on Jan. 20, which included transfer between family members and to health care workers.
It is now obvious that the novel coronavirus spreads quite well in humans. But should the WHO have known that sooner? That’s exceedingly difficult to know, and as we explained earlier, the agency is dependent on countries to give it accurate information.
We can, however, provide some insight into Trump’s more specific claim that there was “credible information” to suggest human-to-human transmission in December 2019. That’s difficult to reconcile with the calendar because the WHO wasn’t notified about the cluster of unusual pneumonia cases in Wuhan until the last day of the month. The agency requested more information from China on Jan. 1.
It has since come out that Taiwan, which is not a WHO member country because it is not recognized by China, claims it sent an email to the WHO asking about human-to-human transfer on Dec. 31. 
As an April 11 Reuters report explains, Taiwan wrote to the WHO because it was concerned about news reports on seven cases that indicated China was keeping patients in isolation. Even though it did not use the words “human-to-human transmission” in its email — which the WHO has noted — the Taiwan Centers for Disease Control has said that the language still should have been clear.
“Public health professionals could discern from this wording that there was a real possibility of human-to-human transmission of the disease,” the group said in a statement. “However, because at the time there were as yet no cases of the disease in Taiwan, we could not state directly and conclusively that there had been human-to-human transmission.”
Given that the WHO had just learned about the outbreak, and had no solid information to go on either, there’s nothing to support Trump’s claim that there was “credible evidence” that early on.
China’s Coronavirus ‘Transparency’
Trump also criticized the WHO for not doing more to make sure China was providing accurate information about the coronavirus outbreak within China’s own borders. Instead, Trump said, the WHO “took it just at face value … even praising China for its so-called transparency.”
What Trump didn’t say is that early on he, too, said he trusted what China was telling the U.S. about the virus.
Trump: Had the WHO done its job to get medical experts into China to objectively assess the situation on the ground and to call out China’s lack of transparency, the outbreak could have been contained at its source, with very little death — very little death — and certainly very little death by comparison. This would have saved thousands of lives and avoided worldwide economic damage.
Instead, the WHO willingly took China’s assurances to face value, and they took it just at face value and defended the actions of the Chinese government, even praising China for its so-called transparency.
Trump is not alone in criticizing the WHO for simply accepting information coming from Chinese officials, and it’s true that WHO Director-General Tedros complimented China for its response to the outbreak in remarks on Jan. 30.
“As I have said repeatedly since my return from Beijing, the Chinese government is to be congratulated for the extraordinary measures it has taken to contain the outbreak, despite the severe social and economic impact those measures are having on the Chinese people,” Tedros said.
He continued: “We would have seen many more cases outside China by now – and probably deaths – if it were not for the government’s efforts, and the progress they have made to protect their own people and the people of the world. The speed with which China detected the outbreak, isolated the virus, sequenced the genome and shared it with WHO and the world are very impressive, and beyond words. So is China’s commitment to transparency and to supporting other countries.”
But Trump originally praised China for its supposed transparency as well.
During a Jan. 22 interview, CNBC’s Joe Kernen asked Trump if he trusted the information coming from China and Trump said he did.
Kernen, Jan. 22: And President Xi — there’s just some — talk in China that maybe the transparency isn’t everything that it’s going to be. Do you trust that we’re going to know everything we need to know from China?
Trump: I do. I do. I have a great relationship with President Xi.
Two days later, Trump sent a tweet expressing appreciation to China for its “efforts and transparency.”
Two weeks after that, Trump told a reporter he didn’t think China was covering up information about the coronavirus, and said China was “doing a very professional job.”
Reporter, Feb. 7: Are you concerned that China is covering up the full extent of coronavirus?
Trump: No. China is working very hard. Late last night, I had a very good talk with President Xi, and we talked about — mostly about the coronavirus. They’re working really hard, and I think they are doing a very professional job. They’re in touch with World — the World — World Organization. CDC also. We’re working together.
And on Twitter, Trump said, “Great discipline is taking place in China.”
A few days later, when Fox News’ Trish Regan asked Trump about China’s transparency, Trump said China was “professionally run” and has “everything under control.”
Regan, Feb. 10: Some concerns that their economy is really going to tank because of this and that that could have a spillover effect here. What’s your sense of their transparency right now, whether they’re being more accommodating in terms of telling us what’s going on and how it affects our economy?
Trump: Well, I think China is very, you know, professionally run in the sense that they have everything under control. I really believe they are going to have it under control fairly soon. … But China I can tell you is working very hard.
A few days after that, in an iHeartRadio interview with Geraldo Rivera, Trump said he couldn’t be certain that China had been truthful about the virus but believed the country had “handled it professionally.”
Rivera, Feb. 13: Did the Chinese tell the truth about this?
Trump: Well, you never know. I think they want to put the best face on it. So you know, I mean, if somebody — if you were running it, you’d probably — you wouldn’t want to run out to the world and go crazy and start saying whatever it is because you don’t want to create a panic. But, no, I think they’ve handled it professionally and I think they’re extremely capable and I think President Xi is extremely capable and I hope that it’s going to be resolved. 
Then, in a press gaggle the following week, a reporter asked Trump if he was worried about data coming out of China, and he again complimented the Chinese president.
Reporter, Feb. 18: Some people don’t seem to trust the data coming out of China. Are you worried about that?
Trump: Look, I know this: President Xi loves the people of China, he loves his country, and he’s doing a very good job with a very, very tough situation.
Even a month later — during a press briefing in which Trump said that China had been “very, very secretive” and not transparent with the U.S. — the president defended his January remarks about China’s alleged transparency.
Reporter, March 21: [A]s you were saying, China was extremely secretive about this. Several of your advisors have been warning — have been critical of China. Secretary Pompeo was talking about it yesterday and he had been saying so —
Trump: Yeah.
Reporter: — for quite some time.
So, why then, on January 24, did you tweet that “China has been working very hard to contain the coronavirus,” that “the United States greatly appreciates their efforts and transparency. It will all work out well.”
Trump: Because it’s true.
Reporter: Why were you saying that, though?
Trump: Because it’s true. China has worked very hard. China has lost thousands and thousands of people.
Reporter: But you said they weren’t transparent, right?
Trump: No, they weren’t transparent. They were transparent at that time, but when we saw what happened, they could have been transparent much earlier than they were.
When Trump was asked during the April 14 press briefing how he could criticize the WHO when “you were saying many of the same things about China just a couple of months ago,” he didn’t answer the question and instead talked about the trade deal he negotiated with China.
The WHO Didn’t ‘Attack’ Trump on Travel Restrictions
Trump said the WHO “attack[ed]” and “actually fought” the U.S. over Trump’s decision to impose travel restrictions on China. The WHO leaders have not publicly criticized the U.S. for that decision, though they did, and continue to, recommend against countries enacting travel restrictions in reaction to the spread of the coronavirus.
On Jan. 30, the WHO declared the coronavirus outbreak a public health emergency of international concern, but the WHO’s emergency committee on the coronavirus said then it “does not recommend any travel or trade restriction based on the current information available.” At a press briefing that same day, WHO Director-General Tedros repeated that message, saying, “There is no reason for measures that unnecessarily interfere with international travel and trade. WHO doesn’t recommend limiting trade and movement. We call on all countries to implement decisions that are evidence-based and consistent.”
Nonetheless, the following day, Health and Human Services Secretary Alex Azar announced travel restrictions to and from China, effective Feb. 2. The policy prohibited non-U.S. citizens, other than the immediate family of U.S. citizens and permanent residents, who have traveled to China within the last two weeks from entering the U.S.
So Trump is correct to say that his decision was made against the WHO’s general advice. But contrary to Trump’s claim, even as the WHO has held regular press briefings about the coronavirus, we couldn’t find evidence that the WHO’s leaders have publicly criticized the U.S. for that decision.
Trump was also mistaken that the WHO’s recommendation against travel bans was tied to a belief that the coronavirus was “not communicable.” The WHO maintained its recommendation against travel restrictions even after emerging information made clear that person-to-person transmission of the virus was happening. On Jan. 14, WHO officials in a press briefing said there may have been limited human-to-human transmission of the virus, and that such transmission would not be surprising given the experience of SARS and other respiratory pathogens. And its Jan. 30 declaration that the coronavirus outbreak was a public health emergency of international concern came two days after the first reports of human-to-human transmission outside of China.
In its updated recommendations for international traffic on Feb. 29, the WHO said: “In general, evidence shows that restricting the movement of people and goods during public health emergencies is ineffective in most situations and may divert resources from other interventions. Furthermore, restrictions may interrupt needed aid and technical support, may disrupt businesses, and may have negative social and economic effects on the affected countries. However, in certain circumstances, measures that restrict the movement of people may prove temporarily useful, such as in settings with few international connections and limited response capacities.”
The WHO added that travel restrictions “may only be justified at the beginning of an outbreak, as they may allow countries to gain time, even if only a few days, to rapidly implement effective preparedness measures. Such restrictions must be based on a careful risk assessment, be proportionate to the public health risk, be short in duration, and be reconsidered regularly as the situation evolves.”
That is part of long-standing policy at the WHO, which has said travel restrictions are largely ineffective and sometimes counter-productive.
A 2014 review of 23 studies on the impact of travel restrictions on the spread of influenza found overall they have “only limited effectiveness,” the degree of which varied depending on the restrictions themselves, epidemic size, transmissibility of the virus and other geographic considerations. The review, published in the Bulletin of the World Health Organization, said: “In isolation, travel restrictions might delay the spread and peak of pandemics by a few weeks or months but we found no evidence that they would contain influenza within a defined geographical area.”
According to a 2005 update of the International Health Regulations, a binding set of rules created by the 194-member states that govern and direct the WHO, countries that enact travel restrictions are required to provide the WHO “the public health rationale and relevant scientific information for it.”
International Health Regulations, 2005: A State Party implementing additional health measures referred to in paragraph 1 of this Article which significantly interfere with international traffic shall provide to WHO the public health rationale and relevant scientific information for it. WHO shall share this information with other States Parties and shall share information regarding the health measures implemented. For the purpose of this Article, significant interference generally means refusal of entry or departure of international travellers, baggage, cargo, containers, conveyances, goods, and the like, or their delay, for more than 24 hours.
Jimmy Kolker, a longtime U.S. diplomat and former assistant secretary for global affairs at the Department of Health and Human Services in the Obama administration, told the health publication STAT that the U.S. was one of the principal authors of the IHR. The idea is not to discourage transparency by countries experiencing an outbreak who might fear financial repercussions if they report it.
“That’s the bargain at the heart of the revised IHR,” Tom Bollyky, director of the global health program at the Council on Foreign Relations, told STAT.
Although the document is technically binding, it has no enforcement teeth, and, Bollyky told STAT, the WHO’s only recourse is to “name and shame” countries that run afoul of the IHR.
While WHO leaders have not publicly criticized countries that have enacted travel restrictions despite the WHO’s advice, like the U.S., they have occasionally reminded the public of countries’ responsibilities under the IHR.
For example, during a Jan. 29 press briefing, Michael Ryan, executive director of the WHO Health Emergencies Program, said that “ensuring that all measures that are being taken that affect travel, trade, and economy are based on rational public health evidence is very important. Again, the IHR is a framework that allows that to happen and that allows public health evidence and public health thinking to drive what are the measures that must be taken to minimize international spread while also minimizing the impact on travel and trade. That is essentially at the heart of what the IHR is about.”
“The IHR does not deny or prevent, it doesn’t prevent a country from taking measures, but what it does is it requires the countries to justify the risk assessment and the value of the public health measures from their perspective,” Ryan explained during a press briefing on Feb. 6. “So, we have to respect the fact that countries have to make certain decisions based on their circumstances, based on the threat that they perceive. And very often, sometimes, based on community perception. The cultural perception of fear for contagion is very different all over the world and governments have to respond also to community expectations and perceptions around protection of their health. So, governments are in a very difficult position. They have a very fine balance to strike. And what we try to do is make that decision transparent and we share that justification with all of the other member states, so at least other member states see what that justification is.”
Trump was also wrong to say that he was “the only leader of a country” that enacted travel restrictions on China. As we have written, dozens of countries imposed travel restrictions on China that came into effect before the United States’ restrictions did, according to ThinkGlobalHealth, a project of the Council on Foreign Relations, which has been tracking the travel restrictions on China due to COVID-19.
One of the co-authors of the ThinkGlobalHealth tracker, Samantha Kiernan, told us the “data shows … that the United States was neither behind nor ahead of the curve in terms of imposing travel restrictions against China.”
“To be fair,” Kiernan added, “the United States was one of the first Western countries to impose any kind of formal travel restriction against China.”
Trump also is exaggerating when he says the U.S. “closed our borders tightly against China.” As we have written, there were exceptions to that halt on travel, including for Americans and their family members. According to a New York Times report on April 4, nearly 40,000 people had arrived in the U.S. on direct flights from China since Trump imposed his travel restrictions. Moreover, the Times found, “screening procedures have been uneven” for those arriving on flights from China.
Finally, Trump claimed he was “the one person” in a room of “21 people” who wanted to enact the travel restrictions. We don’t know who was in the room with him – but, as we wrote when he made a similar boast, Health and Human Services Secretary Alex Azar said the decision stemmed from “the uniform recommendations of the career public health officials here at HHS.”
Impact of U.S. Travel Restrictions
The research on the impact of travel restrictions shows they can delay the exportation of cases, if the restrictions are stringent, but they can’t contain the spread of viruses. Trump, however, repeated his claim that without his travel restrictions on China, “thousands and thousands of people would have died,” adding later, the figure would have been “probably hundreds of thousands more death.” We found no support for such figures.
As we’ve written, we didn’t find a study that looked at the U.S. travel restrictions alone. However, a study published in the journal Science on March 6 estimated that travel restrictions instituted in Wuhan, China, where the coronavirus outbreak began, and those put in place by several countries in early February regarding China would “only modestly” affect the spread of the pandemic. Travel restrictions could delay, but not stop, the spread of the disease, and social distancing and hand-washing behaviors would reduce the transmission of the disease, the study found.
Another study published in the Proceedings of the National Academy of Sciences similarly found that travel restrictions and airport screenings in several countries “likely slowed the rate of exportation from mainland China to other countries, but are insufficient to contain the global spread of COVID-19.”
Past studies also have found some delay in the spread of the diseases, if the restrictions are significant, but not containment.
We found only one study, which wasn’t peer-reviewed, on Australia, that found an impact on deaths. It estimated Australia’s restrictions on travel from China will lower the potential number of deaths from COVID-19 in the country over the next year — but the study didn’t consider any impact of cases coming in from other countries. 
One issue hindering the potential impact of the U.S. restrictions, experts told us, was that they were limited, and the U.S. likely wouldn’t have picked up cases coming from other countries, such as Japan, Singapore, South Korea or even Italy. As we’ve also written, genomic analyses by two groups of researchers suggest a majority of the first cases of the coronavirus disease in New York City resulted from travelers from Europe — and that the virus was being spread around for weeks before the first confirmed case, announced on March 1. The president’s travel restrictions on the bulk of Europe went into effect on March 13. 
Also, while the U.S. restrictions on China went into effect on Feb. 2, Wuhan, where the outbreak began, had already suspended all air and rail travel in and out of the city on Jan. 23, and other cities in the province followed with their own restrictions.
Again, it’s possible the U.S. travel restrictions on China had some impact in slowing the importation of cases, but we don’t have evidence of what that impact was.
In the April 14 press conference, Trump also claimed that countries that hadn’t implemented travel restrictions on China now “have problems the likes of which they cannot believe.” But charts created by ThinkGlobalHealth on the growth in COVID-19 cases by country show no discernible pattern in the arcs of the disease between countries with travel restrictions on China and those without.
ThinkGlobalHealth has found that 96 countries and territories implemented some type of travel restrictions on China.
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