Thursday, June 01, 2006

New rules in a dangerous game

Declan Butler, senior correspondent for the scientific journal Nature, also has a blog and he used it to amplify on his piece in the journal today about the situation in Indonesia. In particular he quotes from correspondence we both have had with Dr. Andrew Jeremijenko, formerly with the influenza surveillance unit of the US Naval Medical Research Unit 2 in Jakarta (NAMRU-2).

Andrew is an astute observer of the scene there, and his correspondence is filled with worry about the inability of the Indonesian central government to cope with the endemic poultry infection throughout this vast country and the continual sporadic appearance of human cases, culminating two weeks ago in the large family cluster in Sumatra which infected all eight members of an extended family and killed seven of them. There was unmistakable evidence of human to human transmission, probably extending to three generations of cases (human to human to human). The actual response was such as to suggest the futility of the kind of almost instant response WHO says will be needed if there is any hope of smothering a pandemic at the source.

Declan gives us the bottom line:
Working at NAMRU-2, Andrew witnessed the enormous gap between the official rhetoric and the reality on the ground. Take the recent declaration by Michael Leavitt, US Secretary of Health and Human Services’ statement to the World Health Assembly: “In closing, I ask this Assembly today to pledge with me to abide by four principles of pandemic preparedness:
  • Transparency,
  • Rapid reporting,
  • Data sharing and,
  • Scientific cooperation.
In reality of course, for many political and cultural reasons — including those of the scientific community itself — although some progress is being made, lip service is often paid to these on the ground, and that includes the US’s own CDC. (Declan Butler's blog)
Declan goes on to reiterate what we have been saying here. WHO has had no inherent police authority over its member states. Under the international system WHO is bound by the principle of state sovereignty and its corollary, non-intervention in the internal affairs of a state. Under the International Health Regulations in effect until last week, WHO may only release information about infectious disease within a member state with the permission of that state. On one occasion only (cholera in Guinea, 1970), a strong and decisive Director-General (Marcolino Candau) ignored the IHR restrictions, but that was the only instance before the SARS outbreak of 2003 that WHO issued any epidemiological information or advice without the assent of a member state. SARS was the signal event that pushed WHO to a more drastic revision of the IHR, going into effect in 2007. WHO's governing body last week authorized it to ask for voluntary compliance for bird flu, one year ahead of time.

The newly revised IHR will require states to respond actively and provide immediate information. WHO hopes this will extend to the vexing problem of release of sequence information, bottled up in the no-man's land of fragmented authority and personal agendas. WHO works with scientists, laboratories and governments around the world and is privy to most of the sequence information. So far it has not gone outside the legal constraints on unilateral release of country information, but that doesn't mean it is powerless. It should be using whatever influence it has -- including withholding isolates from scientists who won't deposit sequence information immediately. Now that the WHA has authorized the early application of the revised IHR to bird flu, WHO should also begin pressuring recalcitrant states using the new authority. Indonesia is a prime candidate for this because it essentially has no central government at all. Instead it continually "yeses" international agencies, so WHO could take those empty assents as a signal the Indonesian sequences are released under the new IHR.

But it's not just state actors that are the problem. Prominent members of the community of flu scientists are also wearing out the world's patience. CDC, St. Jude's, Weybridge, Mt. Sinai and others have unreleased sequence data for H5N1. It is time to deposit them immediately in GenBank or risk losing the respect of colleagues and the public. WHO has no legal obligation to keep sequences that are not from a member state private and they shouldn't. As a data gathering scientist myself I have an appreciation for what this means to the scientists involved. But these aren't ordinary times and the failure of CDC and prominent flu scientists to release all their sequences is reckless, irresponsible and dismaying. Why should China, Turkey and Indonesia do it when the most famous flu scientists in the world won't? Currently they are setting an example of the worst kind. They should set a good one.

There's enough blame to go around here, but it should be placed where it belongs most, with the countries and the scientists. It is time for WHO to start exercising more muscle now that the WHA has authorized it for bird flu.

And there's a lot WHO can do besides issue unrealistic fireblanket scenarios few think will work. They can use the bully pulpit and their own new authority to push countries (including the UK labs and US CDC) to open up the spigot of epidemiological and genetic sequence information. This is an unaccustomed role, but they need to learn to use it quickly.

The revised IHR are new rules in a new game. And the game is dangerous.