The World Health Organization (WHO) is not the world’s health department or the world’s doctor. It is an intergovernmental agency that is part of the United Nations (UN). The UN, despite what hard right wingnuts might think, is not a world government. The international system is technically anarchic, meaning that there is no governing body above nationally sovereign states. For the most part, WHO has no powers beyond those granted it by its member nations (for more background, see our five part series over at the old site here, here, here, here, here). It is only within the last few years that WHO has even begun to bring its approach partially into line with the global reality that infectious diseases don’t care about national borders. In 2007 new International Health Regulations came into force for the first time that impose responsibilities on member states to report diseases of international significance to WHO and allow WHO to issue travel advisories. Those advisories are just that: advisory.
More importantly, WHO can do nothing about states that decide to close borders or ban travel despite WHO’s own advice that such measures are unwarranted. And when they do, WHO cannot prevent them from using WHO as an excuse, whether the action is ulterior motive or mistaken or differing judgment. On the other hand, governments who for whatever reason do not wish to acknowledge WHO’s judgment, are often keen that WHO refrain from announcing to the world something that would be inconvenient for them. Which brings us to the tangle around whether WHO should admit the obvious: that by their own criteria we are at phase 6, i.e., a pandemic with a novel influenza virus is underway.
While I have sympathy for the delicate situation WHO finds itself in with respect to some of its influential member states (the UK, Japan, China to name a few), it is compounding the problem by trying to have it both ways. Finding its system for declaring pandemic phases not well suited to the situation, it is also finding it hard to admit it is changing the basis:
On 29 April, WHO raised the pandemic threat level from 4 to 5, citing sustained community transmission in the U.S. and Mexico. At the same time, WHO said phase 6 was ?imminent? and would be declared if the same type of spread appeared in a second region of the world. But at a press conference today, Keiji Fukuda, WHO’s assistant director-general, said that representatives from several countries who attended the World Health Assembly in Geneva this week criticized the current phasing system, which relies solely on geographic spread without regard to severity of disease.
Fukuda said WHO agreed with the countries that the phase system needs to more accurately reflect the impact the virus is having on populations. Fukuda also said WHO might bump up the alert to phase 6 if the virus started to spread significantly in the Southern Hemisphere, including South America and Africa, even without causing severe disease.
To clarify this confusing potential revision of the definition of phase 6, ScienceInsider asked whether WHO would declare a pandemic right now if the virus were the much deadlier H5N1 that causes avian influenza. ?Even if it were H5N1, we would still be looking for clear evidence of widespread community outbreaks going on in countries in multiple regions,? said Fukuda. ?This is still a situation that we have not seen yet.? (Jon Cohen, ScienceInsider)
It is both fruitless and pointless for WHO to deny it is responding to political pressure. The main question is whether that response is a reasonable and prudent one, given the facts of the situation. I think a good argument can be made that it is, and Fukuda made this case to Cohen:
?What is the value of these phases?? asked Fukuda. ?These kinds of tools are really there to help countries prepare themselves.? For the most part, he said, that has happened, and he stressed that WHO must remain flexible. ?There is nothing like reality to tell you whether something is working or not,? said Fukuda.
This position is also at taken by the Director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota, Dr. Michael Osterholm. As quoted by Canadian Press’s Helen Branswell we think he has it exactly right:
Dr. Michael Osterholm said it doesn’t really matter what the WHO calls the swine flu outbreak, as long as countries monitor it closely and report openly and quickly about what it is doing within their borders.
“I think all we want to do is motivate people to provide the most clear and compelling picture of what’s happening in our communities around the world,” said Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy.
“I don’t want to see a nomenclature debate become the reason why people do or don’t try to understand what’s happening with the disease.” (Helen Branswell, Canadian Press)
Reporting accurately what’s happening within its borders is what the UK Labor government is not doing. They seem to be in an active state of denial, perhaps a defense against a failed (and stupid) policy:
Flu experts are looking very closely at Britain ? and some have decided that the U.K.’s swine flu-fighting tactics are seriously off the mark and may be hiding a much larger outbreak.
Since Britain has the most confirmed swine flu cases in Europe, how the outbreak develops here will have a significant influence on whether the World Health Organization decides to raise its flu alert to the highest level ? a pandemic, or global epidemic.
British authorities have relied on an aggressive strategy to try to snuff out the virus before it spreads, blanketing suspect cases and anyone connected to them with the antiviral medication Tamiflu. (Maria Cheng, AP)
Officially the UK now has 117 cases. “Meaningless” says one of the country’s leading flu scientists:
Thirty thousand people in Britain are likely to have been already infected by swine flu, one of the country’s leading authorities has told The Independent on Sunday. This would mean that the virus is 300 times more widespread than the Health Protection Agency (HPA) admits.
The startling estimate by top virologist Professor John Oxford comes as leading scientists are warning that the agency’s announcements on the spread of the disease are “meaningless” and hiding its true extent. And it tallies with official estimates made in the United States. (Geoffrey Lean, The Independent [hat tip crof’s blog])
If the total is truly around 30,000, most of them are probably are probably undiagnosed mild or inapparent cases. But they are still there, and the idea that the infection can be “snuffed out” with a Tamiflu blanket is ridiculous and a waste of time, effort, money and medication. If the ultimate goal of whatever WHO does with its system is for its member states in Osterholm’s apt phrasing, to “motivate people to provide the most clear and compelling picture of what’s happening in our communities around the world,” then the UK and probably other governments have not met the mark.
Whatever system WHO adopts, it should encourage a clear-eyed view and not the kind of intellectual dishonesty we see in the UK and likely a number of other European countries.