World Health Organization Briefing Update Transcript: March 2, 2020

Dr. Tedros Adhanom Ghebreyesus: (00:00) I have tried to categorize the countries. And you can have a look for yourselves, by the way. Why we say containment works: one, a good number of countries, around eight, have actually not reported cases in the past two weeks ... more than two weeks. Although they had cases before that they had reported, and then they were able to contain it. But in addition to that, if you see what's happening in China, it shows from the result so far that this outbreak can actually be contained, even where there are many cases. So it would it be safe to assume that, especially in countries where they have less number of cases, it's even more possible to contain it. And from the 62 countries who have reported cases, 38 of them have reported 10 or less cases. Actually 36 countries ... 34 countries have reported less than 10 cases and four countries, 10. So that makes sense. So that makes it 38 less or equal to 10 countries. These countries should really invest in containment. And of course, we're also saying at the same time, even if you have more cases, it could be thousands, like for instance Korea or China or Italy, still containment is better. By the way, in Italy, we see that the prime minister is now coordinating the whole effort. The central government and also the local governments are aligned. And we can see a very clear political commitment, and surveillance is now boosted. Of course, they were surprised but they have strong institutions. They're bringing it together. And we have confidence in Italy, and we believe that they can also contain it. So that's what we are saying. Containment is possible in all countries that are affected, and that should be number one. And then of course, the other strategies can also be applied. And that's why also we are saying the comprehensive approach is very, very important. Dr. Tedros Adhanom Ghebreyesus: (02:49) So okay. Giving the overall picture globally, like saying, "Okay, we are close to 90,000. And we have more than 3000 deaths. 65 countries are affected," is fine. But at the same time, let's go down and see what's the situation in each and every country. Like what I said, out of the 62 or 65 countries, 38 are equal to or less than 10 cases. And I can give you even those with more than between, for instance, 14 and 130 cases, which if you take as the lowest, is only ... you have 20 countries. So if you add the 38 and 20 countries, already 58 countries are actually less than 130 cases. 58. And those more than 1000 are only four or five countries. So that's why we're also saying one-size-fits-all approach doesn't work. Blanket recommendation doesn't work. And each and every country should have its own risk assessment and have a tailored approach. But all countries, we believe, should start from containment strategy. Thank you. Terry: (04:05) Thank you very much. Chen, please. And then [inaudible 00:04:10]. Terry: (04:39) Thank you very much, Chen. So the question is that China has said that they will reinforce the cooperation with other countries in response to COVID. So what's your opinion where this cooperation could be reinforced, especially in the light of a meeting we had few weeks ago on research and development? Dr. Maria Van Kerkhove: (05:02) So I could start and then ... So the experience that China has with COVID-19, the work that they are doing in taking an evidence-based approach to this response is something that the world needs to learn from. We have been communicating and working with colleagues in China from the beginning. They have participated at all of our teleconferences across all of the different disciplines. They have participated in the research and development roadmap meeting that we had a few weeks ago. They're continuing to work with us. I've just returned from two weeks in China where we again discussed what they are doing in terms of building an evidence base. And the world needs to learn from them. So we are looking forward to continuing to collaborate with Chinese scientists and public health professionals, across all of the different disciplines, to better understand epidemiology and transmission, to better understand what they're doing around severity and understanding treatments. Dr. Maria Van Kerkhove: (05:53) There are a number of clinical trials that are ongoing in China, and we are awaiting those results. We are still only eight weeks into this outbreak. There are a number of clinical trials that are ongoing, and we're hoping to learn of the results of those very soon. There are diagnostics in terms of molecular diagnostics and serologic assays that are ... that have been developed. There are serosurveys that are being done. There's a number of research studies that are ongoing. And we are working closely with them to better understand what we can anticipate in terms of results coming out and how that will impact our response going forward. So this is a feedback loop. Every evidence, all the evidence that is being gathered as part of this response is fed back into the response so that we can always, always be better and take another approach. Dr. Michael J Ryan: (06:39) In addition, China has sent a technical team to support the response in Iran and has committed to supporting countries with weaker health systems with materials, supplies, and with teams in collaboration with WHO. And that is very much in line with what many other countries are doing. So we very much appreciate that. Specifically at the international level now, with research, we absolutely need the data from the clinical trials that are ongoing for the existing therapeutics. And there's some of that in the US, some of that in China. And we have a strong commitments from our Chinese collaborators on sharing that information as soon as possible. Dr. Michael J Ryan: (07:18) We are establishing a global data safety monitoring board so we can create a centralized way of pooling data. We're working with the NIH in the US, with the European and other institutions in China on a master protocol for clinical trials and for serology studies that will allow us to create common endpoints, common data sets, that will allow us to add value and power to the data we're collecting, and get answers for the world. So the outcome of the meeting a month ago, I think, is now accelerating this collective approach, a standardized approach, but we really do need a ... And I believe they're coming on stream now, but standardized, reliable serology testing is something we absolutely need at this point. And we've just come out of a scientific advisory group meeting this morning with the group for the R&D blueprints. They are currently meeting as we speak, and they're discussing the super priorities, like in accelerating these specific aspects of the research in the coming days. Terry: (08:19) Thank you very much. [inaudible 00:08:20] please. [inaudible 00:08:21] Speaker 1: (08:23) Yes, thank you very much. Apart from the ... Dr. Tedros, is regarding the mission that you sent to Iran. Apart from the flight restrictions to Iran, were there any other difficulties that the mission was facing, for instance to help Iran to tackle the coronavirus? Does the sanctions imposed against Iran affect the WHO mission? Dr. Michael J Ryan: (08:57) [inaudible 00:08:56], but certainly the team didn't just arrive today. The team arrived with the capacity, and reagents, and supplies for over 100 diagno- ... thousand, sorry. 100,000 diagnostic tests, and with PPE that will supply over 15,000 health workers. So the team hasn't arrived without supplies. Clearly, the recent announcements on the easing of sanctions regarding medicinal, medical products and supplies is something that we're very happy and hopeful will continue. Certainly, the health system in Iran needs to be supported. It is a very strong health system, historically very strong, has a proud history of responding to disasters like earthquakes. But clearly, all health systems come under pressure from this disease, and we've seen that at a global level. It doesn't matter what country you're in, this disease will stretch your health system. And therefore, we fully support further support to Iran's medical system in order that Iran may contain this disease, because containing this disease in Iran not only helps Iran, it helps the world. Dr. Tedros Adhanom Ghebreyesus: (10:06) Yeah. I think Mike had already said it. I would like to comment actually the statement from the United States in support of Iran. I think we have a common enemy now, and using health, and especially fighting this virus, as a bridge for peace is very, very important. And UAE support is also another example of solidarity, which we have been calling for some time now. And this is very encouraging, and we would like to actually thank the two countries, but at the same time, call on stressing the importance of solidarity at this time. This virus, these enemies are known, that are something known now, but many unknowns. And it's a common enemy. And we have to stand together in unison to to to fight it. And these early signs are very encouraging. And as humanity, we should stand together. Thank you. Terry: (11:19) Thank you very much. We will go online for a couple of questions from journalists watching us. We will start with National Geographic, and sorry if I mispronounce the name, Nsikan Akpan, can you hear us? Nsikan Akpan: (11:34) Yeah, that was actually right on the mark in terms of my name, so thank you. I appreciate that. My question is about the clinical attack rate. I was wondering if you have an estimate for the clinical attack rate for Wuhan, for Hubei province, or for China as a whole? Dr. Maria Van Kerkhove: (11:56) I'm looking at my cheat sheet. So yes. So as you know, we've just come back from two weeks in China and the Interna- ... I was there two weeks, but the International Mission was there for nine days. And we've just published a very detailed report on the WHO website, and it's in English and in Chinese. It will be on the National Health Commission's website in China. So I do encourage you to read that in full. There's a lot of detail in there around what we've learned about transmission. What we've seen in terms of attack rates, much has been published by the China CDC. There was a paper that came out in the China CDC weekly looking at attack rates by age. And we do see varying levels of attack rates by age. I'm not going to quote what the percentage is from that paper, but we did see some variation in terms of attack rates. Dr. Maria Van Kerkhove: (12:46) For example, we saw low attack rates in children, and that was something ... that is something that is important and warrants some further study. We do see higher attack rates in adults. And what we've seen there is that transmission is occurring amongst close contacts, and that is something that has been confirmed through the data that we've seen in China, and that transmission is being driven by close contacts between families. And so what we've seen is higher attack rates in adults than we've seen in children. Dr. Maria Van Kerkhove: (13:18) In terms of quantifying that specifically, it's still quite early days in terms of what we know. What we're finding are symptomatic contacts because this is what surveillance is focused on. What we need now are population-based serologic surveys. And so these are looking at an age stratified ... looking at all different ages across ... in the general community to really better understand what infection looks like at different age groups. This is being conducted now. These serosurveys are starting to be conducted now. And we hope to have results ... we hope to see some preliminary results of these in the coming weeks. It may be a few weeks before we actually get those. And then we will be able to determine what kind of attack rates we're seeing by age. But right now, we can say higher attack rates in adults ... clinical attack rates in adults versus children. Dr. Michael J Ryan: (14:07) So and just to add, the operative word here being a clinical attack rate because obviously without a serology test, you can't tell how many people have actually overall been infected. But colleagues in Korea and other places as well as in China, certainly in family situations, the secondary attack rate within a family is lower than we would've expected in a respiratory ... with a respiratory pathogen. And the same amongst contacts. The number of contacts followed up now in China is in the hundreds and hundreds and hundreds of thousands. And again, the attack rate in that group is 1 to 5% and 5 to 10%, I think, in family contacts. And they are relatively low in that sense. And similar observations are now emerging in Korea, in South Korea and Republic of Korea. So again, all of this is easy to say, but without ... as Maria said, without a validated serology test, there will always be the doubt that there is a larger proportion of subclinical or non-detected infection going on at community level. Terry: (15:19) Thank you very much. Next question from [Kai Kooferschmitz 00:15:22] from Science. Kai, can you can hear us? Kai: (15:24) Yes, Terry. Thanks a lot. So I did actually read the report. And I'm curious because the report basically makes the point that China managed, with its very extreme measures, to beat back this quite sizable epidemic in Wuhan. So the question for me is what does it mean for the other countries and find themselves at the start of this? Because not every country will be able to implement these extreme measures. And the question to me is at what point do you recommend some of these measures being implemented? When you have a place where you have a few thousand cases? We know that that's a picture of what it was like a week ago maybe. So ... Speaker 2: (16:03) A picture of what it was like a week ago maybe. So I'm curious what your recommendations are. Dr. Michael J Ryan: (16:08) I think you need to look at the experience inside Jubei and the experience in the other 31 provincial municipality, city regions and administrative regions. The measures certainly that were taken in Jubei were extremely aggressive, very, very strong in the face of a massive thousands of cases per day if you cast your mind back, thousands of cases per day. If you look at the experience in the other provinces, the experience in the other provinces is probably more akin to what some countries are experiencing now outside. And the measures that were put in place in those other provinces in China are nowhere close to as stringent as what was put in place in Jubei. So I think we need to, again, when we look at China, is not look at a country that's implemented the same measures everywhere. The measures have been very graduated against to what was perceived as the transmission dynamics at any given time. Dr. Michael J Ryan: (17:04) And those measures have changed over time and have been adapted to each provincial need. So I think matching those measures, but certainly it is clear in the likes of Singapore for example, if you take another example outside in Hong Kong, that measures that have not involved walling off cities or completely banning travel have been very effective in both suppressing and driving transmission down over the last six weeks. So I don't think we're talking necessarily above measures at the Jubei level because quite frankly, other countries may not be capable in terms of their levels of social acceptance or resources to be able to sustain that type of effort for so long. That's a real question mark in our minds. But those measures don't necessarily have to be as aggressive or as robust. And Maria may wish to comment on your observations in Guangdong and Sichuan and other places. Dr. Maria Van Kerkhove: (18:08) Yeah, the point Mike is making about this approach that has been different based on the intensity of transmission is true. And what we've seen in China and what we're seeing in other countries, it's not just China, it's all countries that have been able to slow down this virus. And there are examples of countries outside of China that have been able to slow this virus. They're really applying these fundamental principles of public health. These are public health measures at the core. And this involves identifying cases, aggressively. The earlier and the more action that takes place early on as cases are identified in countries, the better outcome you're going to have in your country. Finding those cases, finding those contexts, following and managing them over the incubation period, making sure that you provide the right provisions to those individuals who are in hospital, providing adequate care, having social distancing, practicing hand hygiene and respiratory etiquette, these things work. Dr. Maria Van Kerkhove: (19:10) There have been some movement restrictions, but as Mike has said, and as we have seen in Wuhan, there's been some very extreme use of these for temporary periods of time. But we are seeing that these have been successful. And other countries can do this. All countries are able right now to talk to their communities. All of them are able to tell the population what they can do and what they should avoid. All hospitals can get ready. That is something that can be applied across the globe. All countries can be looking for cases right now. All countries can be aggressively finding those first cases and following those contexts over time. And we can all help each other and look out for each other. So there's a lot of fundamental things that were done in China that can be done anywhere. Moderator: (19:56) Thank you very much. Our next question is from Sarah from [inaudible 00:20:00]. Sarah, can you hear us? Sarah: (20:01) Yes, thank you. In Dr. Tedros' [inaudible 00:04:07], it was mentioned that there's been a respiratory virus capable of community transmission. Could you clarify what that means? Is the flu not capable of community transmission and what are the implications of a respiratory virus capable of community transmission? Dr. Tedros Adhanom Ghebreyesus: (20:26) I think you have to include the second part. It's capable of community transmission, but at the same time it can be contained, the corona. But if you're talking about another respiratory infection like flu, then we're not able to contain it actually. So that's the contrast. That's what I meant to say. But Mike or Maria, if you want to add here. Dr. Michael J Ryan: (20:56) I think with many respiratory pathogens and especially respiratory viral pathogens, we experience them every winter, we don't necessarily attempt to contain or stop them because we fundamentally believe they will spread unabated. We try to protect ourselves from that individual infection, but we don't have a principle of trying to stop the infection at a societal global level. You don't see restrictions or any measures put in place with seasonal influenza? Yes, we want to protect individuals from seasonal influenza by vaccination or avoiding infection, but we don't implement specific measures at airports or we don't have a terminal screening or any of those things because we have a disease for which we have a vaccine. We have treatments. We understand its transmission dynamics. We understand its patterns. Here we have a disease for which we have no vaccine, no treatment. We don't fully understand transmission. Dr. Michael J Ryan: (21:47) We don't fully understand case fatality. Well, what we have been genuinely heartened by is that unlike influenza, where countries have fought back, where they've put in place strong measures, we've remarkably seen that the virus is suppressed. Or at least the clinical appearance of the virus, the number of clinically apparent cases has been greatly suppressed. And the hope in that is that this virus is, and the DG said it in this speech, it's not influenza and it's not behaving like influenza. It is behaving like Covid 19. The problem is we don't know exactly how Covid 19 behaves, but we know it's not transmitting in exactly the same way that influenza was. And that offers us a glimmer, a chink of life, that this virus can be suppressed and pushed and contained. And at the very least, by doing that, we give all the health systems in the world a chance to prepare and potentially develop therapeutics and vaccines to prevent it. This is about containment and buying time. And in doing that, we can save a lot of lives. Dr. Maria Van Kerkhove: (23:02) If I could just add to that, to what the DG said in his speech about these three C's, you have cases, clusters, communities. What everyone expects is that you go from cases, you go to clusters, you go to communities and that's it. What we are actually seeing is that we're seeing community transmission in some countries actually bring this back down to seeing clusters again, and that is something that we need to learn from and we are learning from. And that is the hope. That is where we can see that you can drive this down, you can bring it back. There is no eventuality here. We're planning for every type of scenario in every type of country. Dr. Maria Van Kerkhove: (23:37) But just because you have clusters of cases doesn't mean you can bring it down to individual cases. Just because you have community transmission doesn't mean that you can't bring that back down to clusters that you can follow. And I think that's really important. We are seeing positives here. We are seeing declines in cases. We're learning from that. That's why we're up here every day talking to you, being so aggressive in our language of saying the time is to act now. The time is to act early. The time is to be aggressive. The earlier you act, the better chances you're going to have, and all of that buys us time. As Mike has just said, this all buys us time to better prepare our systems, our hospitals, the development of medical interventions, vaccines. Moderator: (24:22) Thank you very much. We will take one more question from on the line. Then we will have time for two more questions here in the room. Ms. Banjo Carver from India from Down To Earth. Can you hear us? Banjo Carver: (24:36) Yeah, I can hear you. Can you hear me? Moderator: (24:39) Yes, please go ahead. Banjo Carver: (24:41) Hello. Okay, so Mike, you gave a very detailed statement the other day differentiating between mitigation and containment. Dr. Tedros, you also said that all countries are capable of containing the virus. The European CDC in a statement issued today has said that in the event of established and widespread community transmission, current containment measures may no longer be effective and to have efficient use of resources we have to move into the mitigation phase. So they're saying that containment is not possible in the jurisdiction. I would request you to comment on that. My second question is Dr. Tedros, you were saying that European countries should ask themselves... Moderator: (25:34) We said one question, please. Banjo Carver: (25:35) Just quickly, quick question. That they should have enough ventilators and enough oxygen, et cetera, vital equipment to ensure that we are able to provide good care. Can you define for us, what is that enough? Because what is enough for a big country like India or for a small country like Finland may not be enough for a big country like India. If not in numbers, could you just elaborate what is that enough for us? Thank you so much. Moderator: (25:58) Thank you. Dr. Michael J Ryan: (26:00) Okay. On the issue, I don't believe the US have made... Dr. Maria Van Kerkhove: (26:05) It's ECDC. Dr. Michael J Ryan: (26:06) ECDC or anyone, I'm sorry, have made... Banjo Carver: (26:09) It's European CDC. Dr. Michael J Ryan: (26:09) Okay. Oh, European CDC. I believe everyone's still very much committed to containment. I would hate to think that countries in Europe who currently have no cases are now moving to mitigation, and they will find that quite difficult to explain to their citizens right now. So I do believe that when we speak at a regional level, it's very important that we're not saying that containment has no place in this. And we can see the statement and see what it says. There is a point in any epidemic where you believe you can no longer contain the virus, or like if it was influenza, and you have to shift your resources to saving lives. But in doing that you're accepting that you can no longer affect the course of the disease. You can no longer change the shape of the epidemic. Dr. Michael J Ryan: (27:03) And you're purely moving in that sense to save as many lives as you can. Now, WHO does not believe that we're there yet based on what the director general has presented to you today. We can have that argument. We can sit around the coffee tables all week long and for the next month and we can talk about who's right and we can talk about who's wrong, or we can get on with it. That's the question. History will tell who was right or who was wrong. The real question is we can't miss this opportunity to save lives and we can't miss this opportunities to protect our health systems. So let's just get on with it. Dr. Tedros Adhanom Ghebreyesus: (27:40) Yeah, and earlier I have been saying 38 countries, 10 or less cases. And if you take 11-100 cases, you have additional 17 countries. So 17 plus 38, 55 out of 62, who is less than 100 cases. And I think the figures can show us what kind of strategy actually countries should follow, that they should start from containment. And the number of cases, countries reporting more than 1000 cases, four countries. And we're saying even those countries should actually, in their comprehensive package, they should include containment. And moving from containment to mitigation without testing the containment itself in all those countries I don't think is a wise decision. Even with more cases, more than 1000, having a comprehensive approach is much better than having this strategy which moves into mitigation, which to us, and this I hope is clear, surrendering I don't think is right. So we have to give it our best using containment strategy, irrespective of the number of cases. Dr. Tedros Adhanom Ghebreyesus: (29:26) But this doesn't mean that we will not monitor the situation on a regular basis. We will. And we will adjust our strategies based on that. But in terms of strategy, still whatever the announcement would be, whether it's pandemic or not, we will still go for a comprehensive approach. But in the strategy, the combination of strategies could vary based on the situation. So that's what we're saying. And this is coming from a proper analysis of what has happened in the last two to three months after the announcement or the declaration of this outbreak, where we have seen success with containment strategy and which we believe that it's worthwhile to continue with that kind of strategy. Moderator: (30:27) There was a question on ventilators. Dr. Michael J Ryan: (30:31) Maria. Dr. Maria Van Kerkhove: (30:32) So the question about preparing hospitals for respiratory support and ventilators and oxygen is a good one. This is something that all countries need to be doing some assessments of in terms of what would be needed should they start to see cases. We do know in terms of the severity spectrum, we do know that, excuse me, 80% of those that are infected will have mild disease and recover. We do know that there's approximately 15% that will have severe and another four or 5% that will be critical, which will require oxygen support. So there are some estimates that are coming from the laboratory, excuse me, the clinical teleconferences, which would give some indication of 30-40% of people who are hospitalized that would need oxygen support. And those types of percentages are preliminary. Those types of percentages need to be more refined so that people can prepare for that. And then you need to take that into an assessment of what would be required within your country based on your population, based on the demographics and the underlying conditions in your countries. Dr. Michael J Ryan: (31:40) Just remember most countries, even sophisticated health systems, have very limited intensive care capacity as an overall proportion of the number of clinical beds that they have. So this is not just an issue for the South or for weaker health systems. The careful planning and use of intensive care beds... Dr. Michael J Ryan: (32:03) The careful planning and use of intensive care beds is not a straightforward process. And the idea of just having ventilators, for example, needs trained technicians. ECMO and extracorporeal oxygenation is a process that requires very high levels of skill. It's not just the equipment. So I do think countries need to focus on basic levels of care, basic support to patients early in the course of the disease so that they don't develop the more severe forms of the disease. Early use of oxygen to support people, because most countries will struggle if they start to see large numbers of patients requiring intensive care. It's not a straightforward nor an easy process. And we've also seen that people are spending many, many, many days, up to 20, 24 days in a critical care environment. That's occupying a lot of beds for a very long time. So I think all countries are going to have to think very carefully about how they manage the critical care component of this disease. Moderator: (33:03) Thank you very much. We will come back to the room. [Buddy 00:46:56] and then Gabriela. Terry: (33:09) Good evening. Buddy [inaudible 00:33:12] from Hong Kong. Just to follow up, my colleague from India. Some countries probable in Europe has under estimated this epidemic, and no transparency and probable [inaudible 00:33:26] warnings to public. Do you have any comments on that? And I'm sorry. [inaudible 00:33:35] discrimination against the Iranians or against the Italians? Just give us some comments. Thank you. Dr. Michael J Ryan: (33:40) Yeah, I think we've all been on that merry-go-round once before. We're not in the business that we're apportioning blame to countries, nor to individual ethnic groups. All countries who've experienced this disease have been unfortunate victims of being in the pathway of the disease. What Maria said before and the DG said before is we don't believe that countries are being nontransparent. There's an issue in the beginning of any outbreak when something starts, it's very hard sometimes to distinguish that from all of the other background of winter influenza and other things. And sometimes it's difficult to pick up that signal of what's happening. Dr. Michael J Ryan: (34:22) I've said it and written it myself in the past. And I've done many, many outbreak responses. It's very easy to get caught unawares in an epidemic situation. It's very easy to get behind the curve, to get behind on the back foot. And that happens almost invariably. It almost is a rule of epidemic response. The real question is how quickly you catch up. Do you realize the situation you're in, and can you catch up quickly? And what we're seeing is countries catching up quickly now. Countries really beginning to understand what they're fighting and beginning to take concrete actions towards doing that. We want to push, promote and support those countries who wish to take aggressive concrete action to control this disease, not to start criticizing, apportioning blame or doing all of the other negative things that help nobody. It helps nobody to do this. Dr. Michael J Ryan: (35:09) And particularly when it comes to ethnic profiling of people is not only unhelpful, but it's abhorrent. And we reject it entirely. And the DG has been saying this, solidarity, solidarity, solidarity. We can always, after this outbreak is over, we can sit down and we can see, where did we go wrong? Where could we do things better? Where can we increase transparency? Where can we improve systems? Where can we improve all the things we know now we would love to have stronger? But there's no point looking for something you don't have. You've got to build it now, make it work and then we'll come back and see what we're prepared to invest in future. Dr. Michael J Ryan: (35:49) And it is, the director general has said it. We spend quantums more, thousands, millions times more preparing for every type of other security challenge except a public health one. And we may be paying a heavy price for ignoring preparedness as one of the central measures of human security on this planet. I hope we don't pay too heavier price with us, but we will certainly learn the lessons and hopefully we've learned our lesson this time. Dr. Tedros Adhanom Ghebreyesus: (36:18) Maybe to add to that, to be honest, it's so painful to see the level of stigma we're observing. Of course, we are human beings, we are not angels. We make mistakes. But at the same time we can make rational decisions too. And we can have the right attitude and behavior. And that's what we are calling for. We cannot be angels, but we can be rational human beings who can do the right things and avoid the wrong things. I remember once, this is long time ago. I was very, very young actually. And there was a lot of the stabilization in the world, and somebody was asking a question. When do human beings stand as one, was the question. And another one was responding. This is in school. When we have a common enemy from another planet. Why do we need another enemy from another planet to be one, when we have in the same planet a common enemy that could affect us all equally. So that's what we're saying. There is a common enemy in this planet itself, where we need to fight in unison. And the stigma, to be honest, is more dangerous than the virus itself. And let's really underline that the stigma is the most dangerous enemy. For me, it's more than the virus itself. Moderator: (38:23) Thank you very much, Tedros. We'll take Gabriela and then probably we'll have to conclude. Jamie, there will be another day. Shane too. Gabriela: (38:36) Thank you for taking my question. Gabriela Sotomayor, Mexico, Proceso. Dr. Tedros, as you may know, Covid-19 just arrived in Mexico. We have five imported cases now, but people are a bit skeptical with a laid back attitude. Some say it's a lie disease, they don't understand why so much exaggeration, isolation, containment. So they say that more people die from influenza in the world. So I understand that fear is not an option, but the other extreme is not the solution either. And I know that you have been repeating and repeating the same message, but what can you say to them? And just quick question, what about North Korea? Are you in contact with the health authorities? Thank you. Dr. Michael J Ryan: (39:31) Yeah, we are in touch with the health authorities in North Korea with our office there, and have had multiple meetings here in Geneva with representatives of North Korea. And we've sent equipment, supplies, diagnostic equipment to the North. And again subject to the same release and sanctions and under the proper resolutions. And we know that DPRK has stepped up its preparedness procedures. We're not aware of any cases there right now, I don't think. No. And we're certainly ready to both strengthen our country office and send teams as needed. And I know that North Korea is also in contact with South and also in contact with Chinese colleagues and officials as well. Dr. Michael J Ryan: (40:24) DG will speak to the issue of what you mentioned regarding this outbreak or this epidemic being like flu or not like flu or whatever. It's a difficult position for any individual or organization or anyone to be in, because if you say we have a disease for which we don't know the full transmission dynamics, for which on the face of it has a case fatality of 2% or possibly more in certain circumstances. We're up to, in some cases, 10% of people with underlying conditions can die who present clinically. Then if someone is trying to tell me we shouldn't be trying to stop that and we should just accept that as normal business, then I don't know why I'm doing this job, frankly. Having said that, we have to be very careful. And Dr. Tedros has been very careful since the beginning of this event. Dr. Michael J Ryan: (41:19) We have tried at every possible opportunity to say to people, we don't know. We're hoping... We've said it today, only 80,000 cases, only so many thousand deaths around the world. We're not the ones trying to scaremonger here. We're trying to be realistic. We're trying to be balanced. We're trying to get across the right message. We're trying to tell people what they can do. I'll ask you and others, what are you doing to balance that message on the international front? Dr. Michael J Ryan: (41:45) What's your responsibility in doing that? And if we can all answer that question and go to sleep at night, then we will be better. But I do think that we have been trying to be balanced, as many of you have been balanced in this. China's gone through a huge punch to a system. This isn't just a small little thing that passed over China. This has been a massive punch to the economy, and to the social system and to the health system in China. We don't want the rest of the world to have to absorb that punch. And we're trying to do our best to avoid that. And as Dr. Tedros said, we may not be able to, but we at the same time can prepare, can get ready. We can spread this disease out over a longer period. We can reduce the impact on the health system and the capacity of the health system to absorb that, and make this less impactful on society and on communities. And we hope we can communicate the right level of risk. Dr. Michael J Ryan: (42:41) We've said it again and again. Society should go on. Communities should continue to work and thrive. We don't necessarily need the kinds of measures that have been put in place in Hubei, because we're not there yet in most countries. The simplest and most straightforward public health measures in countries, if applied aggressively and persistently over time, have shown in many countries that the disease can be brought under control. And if we can apply those minimum measures for the maximum time, I think we will make progress. I just hope we're not scaring people unnecessarily. That is certainly not our intention. Dr. Tedros Adhanom Ghebreyesus: (43:18) So what we have been saying repeatedly, Michael said it already, is fear and panic are dangerous, very, very dangerous. Concerns and worries are understandable. And what we are saying is it's fine to be concerned and worried, but let's calm down and do the right things. That has been our message. And from the start, when the number of cases in the rest of the world was so small, it was less than 100 when we declared a public health emergency of international concern. You remember? And it was actually a day, two days after we have seen human to human transmission that we declared a public health emergency of international concern. Less than 100 cases in the rest of the world. And [now it is 00:12:19], actually. And we had window of opportunity. And what we said then was, of course we can have concerns and worries, it's understandable. But let's really calm down and do the right things and use the window of opportunity to contain this outbreak. Dr. Tedros Adhanom Ghebreyesus: (44:39) So still the same message, but in some places, we're not seeing that level of response that we expected. And that's why we have been, again, saying to the world or reminding to the world that the window of opportunity is narrowing, and that we have to still do our best to catch up. So still the same message, comprehensive approach. Of course, we can have concerns and worries, but calm down and do the right things. And there are positive signals. We're not saying this without any reason or facts. I cannot say calm down without seeing any good reason. The good reason is there are successes already in some countries where they have already contained the virus. And [inaudible 00:13:42], 55 countries, less than 100 cases. I leave the question to you, can that be contained? But we're saying not even less than 100 cases, even if it's more, it can be contained. And we have seen already examples, starting from China. So the question now is how hard can we continue to hit it? How committed are we to really hit hard? That's the question. Moderator: (46:08) Thank you very much, Dr. Tedros. Thanks to everyone here in the room and everyone watching. Guys, I'm sorry for all those in the room, but also online who have not been able to ask their question, but we will see each other again. The audio file will be available immediately and transcript, hopefully tomorrow. Have a nice evening. Dr. Tedros Adhanom Ghebreyesus: (46:30) Okay. See you tomorrow. Speaker 3: (46:54) Thank you, Edward. [crosstalk 00:46:54]