by revere, cross-posted from Effect Measure

The finger pointing and the told-you-so-ers are out in force these days and WHO seems to be one of their targets. In the face of wealthy European countries cutting their swine flu vaccine orders because of limited demand, critics are claiming that WHO exaggerated the threat in league with or under the influence of Big Pharma vaccine makers out to make a killing. This is really two issues. One, did WHO appropriately appraise the risk; and two, were they unduly influenced by greedy drug makers. I think the answer to these questions are “Yes” and “No.”

In our view WHO was caught between a rock and a hard place. It is true that a great deal of effort was expended envisioning and preparing for a pandemic that didn’t happen, the bird flu or H5N1 pandemic. That one is still “out there” (along with other plausible pandemic subtypes like H7 and H9) but the one that actually materialized and did produce a genuine pandemic started in a different place, spread faster and had the virulence of seasonal flu rather than bird flu. That meant that the criteria for “calling a pandemic” were not quite right for what really happened. If there was anyone who saw that coming, I don’t know who they were. Yes, there were “bird flu skeptics” (I would call them bird flu deniers, but that’s another argument) but anyone who predicts what influenza A will or won’t do is a fool. No one knows. The best you can do is prepare for what is reasonably plausible and hope for the best. We should be happy that we got one of the better scenarios for a pandemic, because some of what was and remains reasonably plausible is too terrible to contemplate and we weren’t anywhere near prepared for it.

WHO, taken by surprise and being pressured by powerful member states like the UK and China looked, and was, indecisive. All their stated criteria for a pandemic were fulfilled weeks ahead of the actual call but the situation was sufficiently unclear that they hesitated with their finger on the button. In hindsight it’s being claimed they should never have pushed the button. Our view is they should have pushed it sooner. When this virus poked its head above water last spring its future evolution was pregnant with possibilities. Instead of recriminations we should be grateful that — so far — it hasn’t fulfilled reasonable fears, because the recriminations could easily be going in the other direction: why weren’t we better prepared and why didn’t WHO act sooner?

WHO is not the world’s health department. It has essentially no authority beyond what is granted to it by its member states, acting individually and often selfishly. Nor is pandemic flu its main preoccupation. On a pitiful budget it does a powerful amount of good with a vast range of diseases that afflict the world, often in places many of us cannot pronounce. But for global infectious disease, like influenza, its effectiveness is severely hampered by the current international legal framework. It could be argued that in some spheres — and influenza may be one of them — WHO is becoming irrelevant.

The influence of drug companies is more of an example than a condemnation. Yes, big vaccine makers have influence with WHO (and CDC and the EU) because they are the only game in town. But that influence was mainly passive. They weren’t going to do anything significant unless someone guaranteed they could make a buck on vaccines. Their view is that they had a duty to their stockholders to maximize return on dollars invested. Investments in impotence or cholesterol drugs are vastly more profitable than vaccines. Practically this means WHO has to get governments to guarantee their market to the extent there is no risk and hopefully the promise of significant profit. One reason we have had to rely on old egg technology is that Big Pharma didn’t invest much in proving the new technologies that could have made vaccines more quickly and more cheaply. When the time came when we needed them, these technologies hadn’t progressed far enough to allow governmental regulators to recommend their use on hundreds of millions of people.

I’m not letting WHO, big national governments (like the US) or the drug makers off the hook. The former shouldn’t be relying on private companies and a market system that doesn’t work for this purpose; and the drug makers acted only for their private purposes, not the public good (not at all surprising or unexpected). For flu vaccines the market is always too late. We should have had an international system for flu vaccine production that doesn’t have to make obscene profits before it acts, can afford to be inefficient in production, is geographically distribu†ed for the sake of equity and uses the latest technologies it develops under a public license. But we’ve been beating that drum for years and so far we have nothing. Hope springs eternal.

Meanwhile when the pandemic is over WHO says it will examine how it could have done better:

The Council of Europe is planning an investigation, to begin later this month, into whether pharmaceutical companies influenced public health officials to spend money unnecessarily.In Geneva, a WHO spokeswoman acknowledged there were questions to be answered.

She said the the review of its management of the pandemic would be conducted with independent experts, and the results would be made public. (Imogen Foulkes, BBC)

 

I think WHO could have done better but not easily within the present international framework which almost guarantees a distorted outcome. I think CDC got it just about right. Yes, here and there you can point to things that might have been done better. But overall, impressively competent under great pressure. It could have been much better still if we, as a society, had not foolishly decided to disinvest in public health.

Would WHO or CDC or anyone have done things differently if they could see the future? It’s a stupid question but it’s being asked by a lot of stupid people.