Apocalypse Redux

So now we know. The World Health Organisation (WHO) did not ‘fake’ the 2009 swine flu pandemic in order to ‘line the pockets’ of vaccine manufacturers. While its decision may have struck many observers as precipitous and disproportionate, far from being a stooge for the pharmaceutical industry the WHO acted out of the best intentions.

That, at least, was the gloss being put on a long-awaited report into the WHO’s handling of the 2009 pandemic by its director-general Margaret Chan this week.

At first glance, Chan would appear to have good reason to say ‘I told you so’. The Chinese-born public health supremo has endured stinging criticism since her hubristic announcement in June 2009 that the WHO’s global influenza surveillance systems had given the world a ‘head start’ on responding to the swine-origin H1N1 virus that had emerged unexpectedly in Mexico just months before.

One of her harshest critics was the British Medical Journal which, following an investigation into suspected financial links between members of the WHO’s emergency committee that advised on the timing of the pandemic and Big Pharma, warned that Chan’s refusal to disclose the names of the panel members would ‘seriously damage the WHO’s credibility’. At the time, Chan insisted that ‘commercial interests’ had played no part in the WHO’s decision-making process and that she owed the panel members a duty of confidentiality.

This week’s report by the International Health Regulations (IHR) Review Committee is broadly supportive of Chan’s stance. Not only did the review led by Dr Harvey Fineberg, president of the Institute of Medicine, find no evidence of financial ‘malfeasance’, it also found that far from rushing the declaration of a pandemic the WHO delayed the announcement until it was sure the virus spreading between countries in a sustained manner.

For all that Chan will claim that the IHR report exonerates the WHO of wrong-doing, however, the small print contains some sharp criticisms. The overall impression conveyed by Fineberg and his fellow rapporteurs is of an organisation that is over-wieldy and overly-sensitive to criticism. Indeed, the committee found that the accusations of fakery and financial malfeasance stemmed to a large extent from the WHO’s failure to take seriously public suspicions and confusion about the way it had shifted its definition of a pandemic. According to the report, much of that confusion stemmed from an innocent but unfortunately timed technical revision – one that was compounded by some very untransparent amendments to the WHO’s online documentation.

Up until April 2009, the WHO had defined pandemics as causing ‘enormous numbers of deaths and illness’. But on 29 April, with mounting evidence that the H1N1 virus was spreading rapidly to other countries from Mexico and the United States, the WHO suddenly deleted the phrase from its website, replacing it instead with a definition based solely on influenza morbidity (numbers reporting sick) and the degree of spread. To compound the offence and provide further fuel to internet conspiracy theorists, without notice or explanation on 4 May the WHO also altered other online documents so as to make its definitions more precise and internally consistent.

In fact, as the IHR makes clear, these changes had been under discussion for nearly a year and half. According to the report, the WHO’s original definition had been adopted in 2005 to reflect then pandemic concerns about the bird flu virus, H5N1, which although it transmitted poorly between people had, in a handful of cases where it had infected humans, proved extremely lethal. By early 2009, however, with mounting evidence that bird flu was spreading worldwide and that early action could contain and halt its further spread to human populations, WHO experts recommended removing the severity requirement. The result was that from May 2009 all that was required to trigger a pandemic - and those hugely lucrative sleeping vaccine contracts - was sustained ‘human-to-human spread’ in at least two countries in one WHO region plus ‘community level outbreaks’ in at least one country in another WHO region.

When bloggers noticed the changes and drew attention to the coincidence in timing on social media sites, the WHO’s press office was inundated with inquiries. Rather than publish all the documents and dispel the suspicions, however, the WHO compounded them by burying its head in the stand. Thus was yet another conspiracy theory born.

In retrospect, given that swine flu did not turn out to be the ‘Armageddon strain’ many scientists feared, the IHR concludes that the WHO would have done better to retain the severity requirement. The report says it also could and should have done more to dispel the suspicion about the timing of its definition change. At the same time, by insisting on keeping the identities of the emergency committee members confidential, the report concludes, the WHO ‘paradoxically fed suspicions that the Organization had something to hide’. It also recommends that in future WHO adopt more open procedures for ‘disclosing, recognizing and managing conflicts of interest among expert advisers’.

Judging by her hyper-sensitivity on the issue, Chan is unlikely to welcome even these mild criticisms. In the past, she has argued that it was only a stroke of luck that the swine-origin H1N1 virus proved so mild. The irony is that had swine flu proved as virulent as bird flu then we would be thanking her for triggering those sleeping vaccine contracts, not scolding her. As she rather pompously informed the BMJ in an open letter last year, the decision to raise the pandemic alert level was based on ‘clearly defined virological and epidemiological data’ and ‘it is hard to bend these criteria, no matter what the motive’.

In the future, Chan would be advised to put rather less faith in science and use some common-sense, for history shows that the only thing that is truly predictable about influenza pandemics is their unpredictability. Or as the IHR puts it: ‘Lack of certainty is an inescapable reality when it comes to influenza’.