Eight months after the World Health Organization (WHO) declared the swine flu pandemic officially over, an independent expert group has given the global health agency a decidedly mixed evaluation of how it handled the entire episode, from the outbreak's frightening beginning to its lackluster end.
When health officials realized in April 2009 that an unusual number of people in Mexico were being hospitalized and dying from a novel strain of the influenza virus, global health experts girded for the worst: the possibility of a devastating pandemic like the 1918 one that killed up to 100 million people. At the outset, no one could predict that the novel H1N1 virus—a recombination of human, pig, and avian influenza genes—would turn out to be more wimp than monster. If it had lived up to initial fears, says a draft report by the International Health Regulations (IHR) Review Committee, an independent panel of 25 experts convened by WHO, many countries would have faced serious trouble. "The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public health emergency," concluded the committee's draft report, which WHO made public yesterday.
The panel, headed by Harvey Fineberg, president of the U.S. Institute of Medicine, assessed both WHO's response to the pandemic as well as the functioning of the IHR, a legal agreement between countries to coordinate responses to health threats that cross borders. The IHR went into effect in 2007 and had never had a real-world test.
The report praises the IHR and WHO for rapidly kicking into action a global surveillance network and helping countries track the virus and contain its spread. But it has plenty of sharp criticisms, too.
The committee, however, found "no evidence" to support the harshest allegations about WHO: that the organization rushed to declare that the 2009 H1N1 outbreak was a pandemic to enrich the coffers of vaccine makers. In contrast, the report says that WHO delayed declaring a pandemic until it was "undeniably occurring" and faults the organization for not having "a consistent, measurable and understandable depiction of severity." And it says WHO "fed suspicions" about its actions by insisting that Emergency Committee members who gave advice during the pandemic remain confidential and by not revealing their potential conflicts of interest. It further faults WHO for responding to criticisms with "insufficient vigour."
Nearly 80 million people in 77 countries received the influenza vaccine with WHO's help—including providing a "seed" strain of the virus used by manufacturers—but the report says that "numerous systemic difficulties" slowed distribution to low-resource countries. Among the committee's recommendations: establish a Global Health Emergency Corps and a $100 million emergency fund, simplify the six phases WHO agonized over when trying to describe the escalating outbreak (possibly just baseline, alert phase, pandemic), and create advance agreements for vaccine distribution and delivery.
Had this virus caused more severe disease, the committee asserted, "the unavoidable reality is that tens of millions of people would be at risk." It warned that unless "this fundamental gap between global need and global capacity is closed, we invite future catastrophe."
The IHR played "a central role" in the response to the pandemic, the report notes. These new regulations required for the first time that WHO member countries report disease outbreaks that might cross their borders and also stipulated that they provide WHO with scientific rationales if they independently take actions that impede traffic or trade, like restricting travel or banning the importation of pigs. "While the IHR are not perfect, they significantly advance the protection of global health," the report states. The IHR would work better, it says, if it had enforceable sanctions, in particular if a country fails to explain why it restricted traffic or trade—as happened during the pandemic.
David Heymann, an epidemiologist at the London School of Hygiene and Tropical Medicine who formerly worked at WHO as an assistant director general, commends the report's critique. "If the lessons learned that are outlined in the report are applied, the IHR will become more useful," he says.
Panel chair Fineberg declined to speak about the report's conclusions because the draft still must be reviewed by member states before his group writes a longer, final version. But he says that "the committee worked diligently for about a year, hearing from an enormous variety of informants and experts with a whole range of point of views. I feel that the committee presented as balanced and objective assessment as we could." Similarly, WHO says that it will reserve comment until it sees the final draft in early April, in time for it to be digested by delegates attending the World Health Assembly, which starts 16 May in Geneva.