Monday, October 03, 2005

Life as we know it

Just a day after I said on the Geri Guidetti radio show (mp3) I didn't think a pandemic would change life as we know it, the UN's new pandemic czar, David Nabarro told the best flu reporter around, Helen Branswell of Canadian Press, that a flu pandemic could fundamentally alter the world as we know it. So who's right? Not one to back down that easily, I'll just say, we both are.

First, what's going on at the UN? Clearly it doesn't speak with one voice. The old guard at WHO like spinmeister Dick Thompson and his cronies are "don't rock the boat, follow the member states" types. On the othr hand, just as some of us in US public health see the post-Katrina time as a "teachable moment," I sense Nabarro and his allies (and we don't know who they are just yet) see the threat of pandemic flu as an opportunity for global public health.

Last week Nobarro raised eye-brows (and apparently hackles) by suggesting a full-fledged pandemic could kill 150 million people worldwide, far more than WHO's previous public projections of 2 to 7 million. Nabarro's estimates were based on projecting the 50 million figure of the 1918 flu to today's population, roughly three times that of 1918. WHO's official estimates are based on the CDC Meltzer model which uses mortality estimates from the 1968 pandemic, the mildest of the last century. CDC admits it is a "best case scenario" for a pandemic, but WHO has used this number publicly and persistently. Now that Nabarro has gone off the reservation, however, Thompson and company are saying no one knows the correct number and they won't be drawn into scaremongering. We can agree that no one knows what the number will be. But WHO's new found probity reeks of hypocrisy.

Nabarro may be correct that a pandemic would change everythin--for WHO. WHO has operated under an archaic system of international relations that goes back to the seventeenth century when the Peace of Westphalia ended the Thirty Years War. The Westphalian System is built on the principle of absolute national sovereignty (a principle that conveniently ignores actual power relations). It is officially anarchic, meaning there is no power above the sovereign nation state. Practically, this means that the UN, via WHO, cannot coerce member states to do things within their own borders they do not wish to do, i.e., states are the only legitimate governing actors. National sovereignty trumps global welfare. But WHO departed from that in 2003 during the SARS outbreak, bringing in non-governmental surveillance and response elements and issuing effective travel advisories on Canada and southern China. The Canadians were furious and protested loudly. Some of the fallout from this may be playing out in WHO's cautious and hands-off attitude regarding influenza.

But my sense is that Nabarro would still like to consolidate and extend WHO's foray into post-Westphalian territory and the pandemic threat is a means to do this. His interview with Branswell indicates he has not backed off his earlier stance to announnce pandemic flu as a grave and looming threat requiring urgent action.
Progress will demand appealing "to people's recognition that we're dealing here with world survival issues - or the survival of the world as we know it," Nabarro explains.

"And therefore we just can't go on approaching it with sort of business-as-usual type approaches."


"Governments have realized that this is something to be worried about," he says, adding the UN must harness that concern and the resources it frees up.

"It's a rare thing, political commitment to deal with a health issue. And when you've got it, you must use it well," he insists.

"We're not going to have such an excellent window of opportunity to really start moving forward with this for long. And so we must take advantage of it now."
I am reading between the lines here in saying Nabarro's statement refers to alteration in the classical system of international relations rather than the everyday life of people, the reference in my own radio interview. This is based to some extent on my reading of what is going on within the UN and WHO, as evidenced by the wildly oscillating and contradictory statements issuing from there. But I'll grant you it might be interpreted more literally.

I'm on Nabarro's side in this. Let's get ready for whatever might happen and not argue about numbers that are probably meaningless to most people, anyway.