The over-reaction to H1N1 influenza in 2009 was built on years of waiting for ‘the Big One’.
Over the past few days, the sixty-fourth session of the World Health Assembly (WHA) has been held in Geneva. The WHA is the highest decision-making body of the World Health Organization (WHO). It is comprised of delegations up to ministerial level from the WHO’s 193 constituent member states.
Among the agenda items was to be a discussion of the International Health Regulations 2005 (IHR) in relation to pandemic A (H1N1) 2009 – colloquially known at the time as ‘swine flu’. The IHR first came into force in 2007 and were established to facilitate international cooperation in preventing and responding to acute public-health emergencies, such as the outbreak of influenza that appeared to originate in Mexico two years ago.
The 180-page report, presented by the IHR Review Committee to the WHA, certainly seems impressive. Aside from receiving numerous national and institutional inputs, well over a hundred individuals from a vast array of agencies worldwide, including the WHO, contributed in some form to its findings.
But, in essence, only one point of any note is made in it: ‘Critics assert that WHO vastly overstated the seriousness of the pandemic. However, reasonable criticism can be based only on what was known at the time and not what was later learnt.’ This is felt to be of such significance that it is stated three times – in the executive summary, in a slightly modified form in the body of the text, and again in the conclusions. It is intended as a robust rebuttal to those voices – in the media, the medical professions, and elsewhere – who have questioned the global response to H1N1, and the WHO’s role in shaping this response.
Foremost among these has been Paul Flynn, a British Labour MP and rapporteur to the Social, Health and Family Affairs Committee of the Council of Europe, through which he successfully promoted an inquiry into the matter. This inquiry primarily questioned the role of advisors to the WHO, who – through being employed by large pharmaceutical companies that produce anti-viral drugs and vaccines – were held to have had an economic motivation in raising public concerns about swine flu.
The editor of the British Medical Journal, Fiona Godlee, and others, have similarly pointed to possible conflicts of interests, as well as a lack of transparency within the WHO relating to advice and appointments. Sam Everington, former deputy chair of the British Medical Association, went on the record to argue that, in his opinion, the UK’s chief medical officer and the government were ‘actively scaremongering’.
Quite a number of countries worldwide have also raised criticisms since the pandemic abated, ruing the fact that they purchased vast stocks of vaccines at some considerable cost that have remained unused.
But, just as with the official review of the UK’s response into the outbreak, these voices and views are simply non-existent as far as the IHR Review Committee and the WHO are concerned. And anyway, as the report repeatedly reiterates, it is the considered opinion of international public-health specialists that claims of over-reaction to what turned out to be a comparatively mild illness are misguided. Those who point to this are held to be cavalier and complacent as to the possible risks entailed should the situation have been different.
What’s more, much emphasis is placed in the report on the fact that Margaret Chan, the director-general of the WHO, and other WHO staff consistently tried to calm matters down, repeatedly noting that the overwhelming majority of cases were mild and recommending to governments that there was no need to restrict travel or trade. If anyone went beyond the measures that were officially advocated then the WHO could hardly be held responsible for this, the report contends. Hence it is to the media, and in particular new social media, that blame is attached.
But all this is to woefully misunderstand and underestimate how communication about risk affects contemporary society. Regulations and warnings are not issued into a vacuum. People and institutions do not merely respond to messages on the basis of the precise information contained within them. Rather they interpret these through the prism of their pre-existing cultural frameworks.
For example, when the former UN weapons inspector Hans Blix advised the world in 2002 that he could find no evidence for weapons of mass destruction in Iraq, it is quite clear that, rather than reading this at face value, the response of the US authorities was to assume that any such weapons were simply well hidden. In other words, they did not allow the facts to stand in the way of their mental model of the world – one in which that the Iraqi authorities would invariably lie and operate surreptitiously, regardless of evidence to the contrary.
Likewise, whatever the WHO likes to think it announced about the outbreak of H1N1 influenza in 2009 – ignoring, presumably, the fact that the director-general herself described it as ‘a threat to the whole of humanity’ – its officials should also have been sensitive to the reality that their messages would emerge into a world that had steadily been preparing itself for a devastating health emergency for quite some time.
Indeed, much of this ‘pandemic preparedness’ had been instigated and driven by the WHO itself. It is quite wrong therefore for the IHR Review Committee report to argue that any criticism of the WHO was based on ‘what was later learnt’. It is clear that the global public-health culture that the WHO itself helped to create in advance would inevitably result in just such an over-reaction. It is even possible to go further than this and to predict right now that this will not be an isolated incident. Lessons may be learnt, but mostly the wrong ones.
A critical article in Europe’s largest circulation weekly magazine, Der Spiegel, published just over a year ago, noted how prior to the advent of H1N1 in 2009, ‘epidemiologists, the media, doctors and the pharmaceutical lobby have systematically attuned the world to grim catastrophic scenarios and the dangers of new, menacing infectious diseases’. Indeed, it seemed at the time of the outbreak, to one leading epidemiologist at least, that ‘there is a whole industry just waiting for a pandemic to occur’.
In this, as the IHR Review Committee report makes clear, ‘The main ethos of public health is one of prevention’, before continuing: ‘It is incumbent upon political leaders and policy-makers to understand this core value of public health and how it pervades thinking in the field.’ The authors appear to believe that this is a radical outlook; in fact, this precautionary attitude is the dominant outlook of our times. In that regard at least, the WHO and others were merely doing what came naturally to them when they acted as they did in 2009.
It is the case today that both elites and radicals view the world in near-permanent catastrophist terms. This apocalyptic outlook emerged as a consequence of the broader loss of purpose and direction that affected society in the aftermath of the old Cold War world order that last provided all sides of the political spectrum with some kind of organising rationale.
Indeed, it was as the Cold War was drawing to a close that the concept of emerging and re-emerging infectious diseases first took hold. And, as noted by the American academic Philip Alcabes in an excellent book on these issues, it was also the point at which the notion of dramatic flu epidemics occurring on a cyclical basis – which until the 1970s had been little more than one of many possible theories – also came to form an essential component of the contemporary imagination.
In the autumn of 2001, the anthrax incidents that affected a tiny number of people in the US in the aftermath of the devastating 9/11 terrorist attacks, were heralded as a warning of things to come by the authorities. As a consequence, after many years of being regarded as an unglamorous section of the medical profession, public health was catapulted centre-stage with vast sums made available to it by military and civilian authorities to pre-empt and prevent any bioterrorist attacks that they now all too readily anticipate.
The outbreak of a novel virus, severe acute respiratory syndrome (SARS), in 2003 – a disease that affected few individuals worldwide but had a relatively high fatality rate – was held by many to confirm that we should always prepare for the worst.
Since then it has been the projected threat of H5N1 ‘avian flu’ jumping across the animal-human barrier that has preoccupied the world public-health authorities. Irrespective of the fact that there have been just 553 cases of H5N1 since 2003, concerns generated by it have been sufficient to push through far-reaching transformations to the world public-health order – including the advent of the IHR themselves.
Now – ominously – aside from deflecting any responsibility for the confusions they helped to create, by describing the H1N1 episode as having exposed ‘difficulties in decision-making under conditions of uncertainty’, the IHR Review Committee note in conclusion that – looking forwards – their most important shortcoming is that they ‘lack enforceable sanctions’.
In this regard, public health will not just be perceived of as being a national security concern – as it has already become in many influential circles – but also one requiring effective policing, possibly with its own enforcement agency, through the establishment of a ‘global, public-health reserve workforce’, as the report suggests.
Aside from absolving the IHR and the WHO of any responsibility for the debacle that saw large numbers of well-informed healthcare workers refusing to be inoculated when the vaccine eventually emerged in 2009 – thereby encouraging the public to act in similar fashion – the report of the Review Committee is also a call to make risk communication more of a priority in the future.
But, far from the public requiring the authorities to speak more slowly, more clearly or more loudly to them, it was precisely the attempted communication of risk – where there was little – that was the problem in the first place. That is why we can be sure that this problem is set to recur, at tremendous cost – both social and economic – to society.
Risk is not simply an objective fact, as some seem to suppose. Rather, it is shaped and mediated through the prism of contemporary culture. That we perceive something to be a risk and prioritise it as such, as well as how we respond to it, are socially mediated elements. These may be informed by scientific evidence but, as indicated above in relation to Iraq, broader trends and outlooks often come to dominate the process.
These are impacted upon by a vast number of social, cultural and political variables, such as the cumulative impact on our imagination of books, television programmes and films that project dystopian – or positive – visions of the present and the future. Another major influence is the perception of whether the authorities have exaggerated or underestimated other problems, even such apparently unrelated matters as climate change or the 2008 financial crisis.
An emergency then – whether it relates to health or otherwise – does not simply concern the events, actions and communications of that moment. Rather, it draws together, in concentrated form, the legacies of past events, actions and communications as well. And while it may not have been in the gift of the IHR Review Committee to analyse, and – still less – to act upon all of these, there is precious little evidence that they considered such dynamics – and their own role within them – at all.
Far from struggling to convey their messages about H1N1 through a cacophony of competing voices – as some within the WHO seem to suppose – the authorities concerned totally dominated the information provided about the pandemic in its early stages. Their mistake is to presume that it was merely accurate information and the effective dissemination of it that was lacking.
Rather, it was the interpretation of this information according to previously determined frameworks that had evolved over a protracted period that came to matter most. Accordingly, the WHO tied itself in knots issuing endless advisories at the behest of the various nervous national authorities it had helped to create. This even included guidance on the use of facemasks which, whilst noting a lack of any evidence for the efficacy of these, nevertheless conceded that they could be used, but if so that they should be worn and disposed of carefully!
At the onset of the 1968 ‘Hong Kong’ flu epidemic, that killed many tens of thousands more than H1N1, the then UK chief medical officer postulated – erroneously – that he did not envisage the outbreak being a major problem. Far from being lambasted for being wrong, or hounded out of office, as he might be in today’s febrile culture, it appears that the presumption of the times was that it was precisely the role of those in authority to reassure and calm people down, rather than to issue endless, pointless warnings as we witness today.
The WHO, on the other hand, seems determined to assert its moral authority by projecting its worst fears into the public domain. Sadly, it seems, the authorities have not learnt a single lesson from this episode.
It is not the actions of the individuals concerned that the IHR Review Committee report should have scrutinised and sought to exonerate from presumptions of impropriety or personal gain, but rather the gradual construction of a doom-laden social narrative that WHO officials have both helped to construct and now need to respond to, that urgently needs to be interrogated.
First published on spiked, 23 May 2011