A Pandemic Backlash

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By Julie E. Fischer – When a house is on fire, the first order of business is saving everyone inside. Few would accuse the fire department of overreacting by responding at once to every alarm. Maybe some fires wouldn’t spread, but those watching their own houses smolder would probably not advocate that firefighters hedge their bets. However, a small but vocal group of critics of the World Health Organization and its new authorities to govern the response to global health emergencies seems willing to do exactly that.

A little over a year ago, health authorities in Mexico uneasily noted intense respiratory disease activity at what should have been the end of flu season. As Mexico stepped up surveillance, two children in California tested positive for influenza of an unknown type. Laboratory tests of specimens from both countries confirmed the cause: a novel influenza virus of swine origin, to which most of the world’s population lacked any pre-existing immunity.

By mid-April 2009, 214 countries and territories worldwide had reported infections – the very definition of a pandemic.

The fact that we could track the spread of the 2009 H1N1 pandemic throughout North America, Europe, Asia, and finally worldwide in near real-time did not stem from new technologies, but from a new framework for global health cooperation.

In 2003, the SARS outbreak illustrated the consequences of one nation’s failure to report an emerging infectious disease. The price tag of SARS – estimated at $30-60 billion – catalyzed adoption of the revised International Health Regulations (IHR 2005) by all WHO member states.

They grant WHO new authorities to collect information on health events, including from unofficial sources, and to coordinate the international response. And, unlike other global health initiatives, the core competencies are legally binding.

When Mexico and the US reported their novel influenza findings, WHO convened an expert committee to evaluate the threat as directed by the IHR 2005.

On April 25, 2009, the WHO Director-General declared the unfolding H1N1 influenza pandemic the first public health emergency of international concern since the revised regulations entered into force in 2007. WHO activated its own pandemic preparedness plan, which included pandemic alerts based on geographic spread, rather than disease severity.

Obviously, this pandemic fell short of doomsday scenarios, although “mild” seems an inappropriate description for a virus that claimed nearly 18,000 lives worldwide in one year by the most conservative estimates.

National and international health experts did not anticipate that an ever more finely tuned global disease surveillance network might uncover an unexpectedly moderate pandemic on its first spin – or more accurately, did not anticipate the political backlash.

As WHO hovered on the edge of declaring a full-blown pandemic, public health leaders criticized the delay, while political leaders concerned about economic impacts urged restraint.

When worst-case scenarios failed to materialize, wealthy communities moved from relief to resentment. Long-simmering suspicions about vaccine safety erupted into outright skepticism of government motives. Many Europeans and Americans at high risk for influenza complications spurned H1N1 influenza vaccines once they became available. Developing nations continue to clamor for vaccines, while elsewhere shipments costing millions of dollars will expire unopened.

A Council of Europe committee accused WHO of trumping up a “fake pandemic” under duress from the pharmaceutical industry. WHO officials strenuously deny this charge, pointing credibly to reliance on pre-determined criteria and decision-making processes outlined in the pandemic plan and the IHR, respectively.

When WHO named a panel of external experts to review its performance, critics derided the committee itself as inherently biased. Although the number of critics appears small, the intensity of their accusations has launched the after-action examination of the public health response to H1N1, a normal part of the learning process, on a defensive footing.

Second-guessing WHO’s reaction to H1N1 pandemic influenza is easy enough, but labeling the entire international response an overreaction simply ignores biological realities.

Influenza evolves unpredictably. We still lack the technologies to produce vaccines in less than six months. If H1N1 had returned in more lethal form in the fall of 2009, health authorities would most likely have been accused of under-preparation by populations increasingly intolerant of risk.

The H1N1 influenza pandemic left smoke and fire damage, but the architecture of the IHR (2005) still stands. The regulations embody a commitment to reciprocal responsibility among all nations on the principle that, in an era of accelerated globalization, not even an island is an island.

The first real test of the framework provided yet another reminder that the foundations for public health in many nations are shaky at best. Rather than a false alarm, H1N1 pandemic influenza may yet be a useful wake-up call – particularly if skeptics are willing to listen.

Dr. Julie Fischer is a senior associate at the Stimson Center, a Washington-D.C.-based nonprofit, nonpartisan institution devoted to enhancing international peace and security. She heads the Center’s Global Health Security Program.

Dr. Rebecca Katz is an Assistant Research Professor at The George Washington University School of Public Health and Health Services in the Department of Health Policy.

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