Charges that the World Health Organization (WHO) exaggerated the risk of the H1N1 pandemic in collusion with drug companies came to a head in a January 26 hearing of the Council of Europe’s Committee on Social, Health and Family Affairs. Lisa Schnirring covered the story for CIDRAP News, an online service of the University of Minnesota Center for Infectious Disease Research & Policy.
While Lisa was working on her article, I sent her an email offering some comments. My wife and colleague Jody Lanard did so as well (at Lisa’s request), and Lisa wound up quoting us both. I intended to post my original email to Lisa, as I usually do. But instead, Jody and I collaborated on this expansion of the email, documenting in more detail the points I had made briefly in the original.
—Peter M. Sandman
Council of Europe allegations of WHO conflict of interest – organizing a “fake pandemic” in order to enrich the pharmaceutical industry – are pretty bizarre. The reigning ideology at WHO is anti-corporate, and this is particularly noticeable when it needs to cooperate with Big Pharma in the service of public health. We wrote about this phenomenon back in December 2004, when WHO was trying to persuade the industry to gear up its vaccination manufacturing capacity for a possible bird flu pandemic.
Also bizarre: The critics seem unable to distinguish between a “fake pandemic” and one that has turned out less severe (so far) than any of us dared hope at its outset. This is the worst sort of outcome-biased thinking.
But we think WHO has set itself up for unjustified criticism in much the same way that the IPCC has set itself up for a similar loss of credibility in the global warming realm. They have both committed the same risk communication sin: failing to acknowledge the small piece of the truth their critics are getting right.
For WHO, the critics’ two strongest arguments are:
WHO continued to deny that the pandemic’s early waves were mild long after it looked like the death toll (barring an increase in virulence) would be way below earlier best-case pandemic scenario predictions of 2 million to 7.4 million deaths, well below first impressions from the early data from Mexico, and probably below the average seasonal flu death toll.
The “2 million to 7.4 million” figure was used fairly often by WHO before the appearance of swine flu. A 2005 WHO report , for example, says: “Best-case scenarios, modelled on the mild pandemic of 1968, project global excess deaths in the range 2 million to 7.4 million.” WHO never told the world that the swine flu pandemic looked like it would fall far short of the two million mark if it didn’t become more virulent.
We can understand WHO’s dilemma. There was and is reason to worry – and to warn – that later waves might become more severe, and that even early waves might have a more severe impact in the developing world than they were having in developed countries. Nonetheless, this is one germ of truth underlying the false allegation of a “fake” pandemic. It wasn’t and isn’t a fake pandemic. But so far it has been a mild one, and WHO has been excessively reluctant to say so.
Until very recently, WHO has routinely included some consideration of severity in its various definitions, descriptions, and discussions of the word “pandemic” as applied to influenza.
Sometimes it did this in quite extreme terms. Consider this example, from a speech by then-WHO Director General Lee Jong-wook: “Flu pandemics in the past have been lethal on a massive scale. There were between 20 and 50 million deaths in the 1918 flu pandemic. In the pandemics of the 1950s and 1960s, 5 million people died. Those were considered mild pandemics.… Above all, the public must know what is a pandemic and what is not.”
More formally, a WHO webpage on “Pandemic preparedness” had this to say:
An influenza pandemic occurs when a new influenza virus appears against which the human population has no immunity, resulting in several, simultaneous epidemics worldwide with enormous numbers of deaths and illness.
The link is to a WHO webpage no longer on its website but archived elsewhere. The page may load very slowly. Here’s a screen shot.
Of course it’s arguable that there are “enormous numbers of deaths and illness” from influenza every year. But we think most people would agree that describing a pandemic this way strongly suggests that people should expect way more deaths and way more illnesses in pandemic years than in interpandemic years.
Other times, WHO documents have framed severity in less extreme terms, as in this 1999 guidance document :
The Pandemic will be declared when the new virus sub-type has been shown to cause several outbreaks in at least one country, and to have spread to other countries, with consistent disease patterns indicating that serious morbidity and mortality is likely in at least one segment of the population.
Without specifying how severe is severe enough, the 2005 WHO Pandemic Influenza Plan includes severity as one of the factors that “may” be considered in ratcheting up from one pandemic phase to another:
The distinction between phase 3, phase 4 and phase 5 is based on an assessment of the risk of a pandemic. Various factors and their relative importance according to current scientific knowledge may be considered. Factors may include: rate of transmission; geographical location and spread; severity of illness; presence of genes from human strains (if derived from an animal strain); other information from the viral genome; and/or other scientific information.
Only the most recently revised WHO influenza pandemic guidance plan omits any mention of severity in describing the pandemic phases. That revision, underway since 2007, was hurriedly published in late April 2009, just after the emergence of the novel H1N1 virus in California and Mexico.
By failing to concede these two points – that the early waves of the H1N1 pandemic have been mild, and that considerations of severity were included in previous WHO flu pandemic descriptions/definitions – WHO gives unjustified credibility to the critics’ other, much less valid claims.
And WHO has found it impossible to argue coherently that even the mild pandemic waves of 2009 satisfied most if not all of the severity-related criteria in previous WHO documents. The argument is available, but WHO can’t make it – because WHO won’t address the mildness of those waves or the existence of those severity-related criteria. For the same reason, WHO hasn’t felt free to point out that under its 1999 and 2005 pandemic guidance documents, it would have had to declare that the spread of novel 2009 H1N1 had reached pandemic proportions much sooner than under the revised 2009 guidance. Far from triggering a premature pandemic declaration because it lacked “severity” language, the 2009 revisions actually incorporated “geographical spread” language that justified a delay in declaring the 2009 pandemic.
And WHO does more than “fail to concede” these points. In recent days both WHO spokesperson Gregory Hartl and Keiji Fukuda, WHO’s Special Advisor to the Director-General on Pandemic Influenza, have said things that look to us like conscious deception (via carefully chosen words), especially with regard to the role of severity in assessing the emergence of an influenza pandemic.
“A pandemic has nothing to do with severity or number of deaths,” Hartl told the Associated Press on January 25. “A pandemic literally is a global spread of a disease.” It is hard to reconcile this categorical statement – narrowly defining the generic word “pandemic” – with all those references to severity in various WHO documents about the nature of influenza pandemics.
Hartl also declined to acknowledge WHO’s avoidance of the word “mild” to describe the H1N1 pandemic, asserting instead that “we always described the virus as causing overwhelmingly mild disease.” This is literally true, and quite beside the point. All influenza pandemics to date have caused mostly mild cases. This was true even of the horrific 1918 pandemic (which no one would call mild); roughly 2% of those who got sick died, which means that roughly 98% recovered, mostly with very little medical care. What has made the 2009 pandemic mild so far isn’t that most individual cases have been mild. It is that the recovery rate has been something like 99.98%, not 98%.
“Did WHO change its definition of a pandemic?” Dr. Fukuda asked rhetorically at a WHO news conference on January 14. “The answer is no, WHO did not change its definition.”
Dr. Fukuda makes this a defensible claim by confining himself to a strained, legalistic meaning of what constitutes a “definition of a pandemic”: only formal definitions count, not mere descriptions; and only generic definitions that apply to all kinds of pandemics, not definitions/descriptions of influenza pandemics in particular. Thus:
Let me start by pointing out that there are many sources that any of you can go to, to look up the word pandemic, and find the definition and you can find these in textbooks, you can find these simply by going to the web, and typing in “definition of pandemic.” What you’ll find is that definitions are sometimes worded somewhat differently but all of them basically agree that the pandemic is a worldwide spread of an infection or a disease.
But the topic under discussion at the news conference – and under the microscope of critics – wasn’t the formal definition of a generic pandemic. The topic was the World Health Organization’s inclusion of severity in much of what it had to say about the nature of influenza pandemics over the past 15 years – until April 2009.
WHO’s revisionist history is very easy to rebut, because it is demonstrably false.
A cardinal principle of risk communication is the need to acknowledge the valid elements of your critics’ claims. This is especially the case when your critics are skeptical, angry, frightened, upset, or outraged; when they are beginning to attract others to their cause; and when many of their claims are wrong. Under those circumstances, defending the indefensible is unstrategic as well as unethical. Far better to concede what must be conceded, and save your credibility to dispute the false charges: Yes, we should have been clearer that the H1N1 pandemic has been mild so far. And yes, we have long considered severity a relevant factor in assessing influenza pandemics and even in defining them. But no, the pandemic of 2009 is not a fake pandemic. And no, WHO has never been interested in helping pharmaceutical companies make a killing.
Good guys (like public health officials) have a much harder time than bad guys (like corporate polluters) learning that they need to concede the validity of valid criticisms, even when they’re packaged with invalid ones. Self-deception keeps WHO officials from realizing that the critics are right about the two issues discussed above. Self-righteousness keeps WHO officials from acknowledging it even at those moments when they realize it.
Good guys can often get away with self-deception and self-righteousness; sometimes they get away with it for quite a long time. Corporate officials know they’ll be crucified by the media if they get caught distorting even a small piece of the truth. Public health (and climate change) officials, on the other hand, know they’ll get a free pass on such distortions … until suddenly their free pass expires, and then they reap what they have sown.
That's what’s happening to WHO in Europe this week. It is very sad to watch.
Copyright © 2010 by Peter M. Sandman and Jody Lanard