Tuesday, June 06, 2006

WHO, part IV: one door closes, another door opens

[This is the fourth of several posts (part I, part II, part III, part V) giving some background to the place of WHO in the international system. I am trying to explain some things about WHO behavior and positions I think might be useful to interpreting their actions and statements. It is not meant as a defense of either.]

Westphalian public health, as embodied in the International Health Regulations, was obviously a failure, and revision of the IHR was in order. The revision process began quietly in 1995. Early on it was realized that just adding to the list of notifiable diseases (including HIV/AIDS, for example) was not going to solve the serious structural problems caused by reliance on states as the only legitimate actors and sources of information. The member states were often blatantly disregarding their obligations to notify WHO, and through WHO, other member states. Adding to the list of diseases wasn't going to help much. The goal of the revision remained the same, however: to prevent the cross-border spread of infectious disease while interfering a little as possible with trade and travel (see also, the excellent monograph by David Fidler, SARS, Governance and the Globalization of Disease). The key move was to include information of non-state origin as legitimate sources of epidemiological information. This was a conscious break with Westphalian principles because it shared governance with non-state actors.

It was also a formal recognition of a fact. On the one hand, depending on states to divulge information that might damage them was unrealistic and obviously a failure. On the other hand, WHO and global health experts were already using to good effect non-state sources of information: newspapers, websites, chatrooms and email lists -- all the capabilities of the exploding new information technologies we know as the internet. In the mid nineties the Program for monitoring emerging Diseases (ProMED) was formed to harness the internet for a rapid dissemination of diverse sources of information. Today ProMED has tens of thousands of subscribers in more than 150 countries. Many of us receive it by broadcast email and its website is open to the world. It is currently sponsored by the International Society for Infectious Diseases, an NGO.

This kind of information was not just harvested, but also used by WHO in a new Global Outbreak Alert and Response Network (GOARN), which started operation in 1998. On paper GOARN was impressive:
This overarching network interlinks, in real time, 110 existing networks which toegether possess much of the data, expertise, and skills needed to keep the international community alert to outbreaks and ready to respond . . . .[o]ne of the most powerful new tools for gathering epidemiological intelligence is a customized search engine that continuously scans world Internet communications for rumors and reports of suspicious disease events. (WHO, as quoted in Fidler, p.. 66 - 67).
WHO claimed to have used GOARN to identify and investigate 538 outbreaks of international concern in 132 countries between 1998 and 2002. I have no way to verify this. But Karl Greenfeld, in his new book on SARS (The China Syndrome), points out that at the time of the SARS crisis, GOARN was in reality just three full-time medical professionals operating out of two offices on the first floor of the WHO annex building in Geneva. GOARN got its information from the same sources we do at Effect Measure: ProMED, media reports, websites, local correspondents and rumors.

On February 11, 2003 GOARN detected a developing respiratory disease outbreak in southern China, about a month after the Chinese government sent a team of doctors to Heyuan Number One Hospital to see the first cases of what later came to be know as SARS that came to its attention (they did nothing about it). Initially, the WHO suspected this was the start of an H5N1 outbreak and they alerted their laboratory network immediately, although public notification didn't come until weeks later. One might say that GOARN had "worked" much better than leaving it to China to report, but there was still a sufficiently long lag time that hads it been the start of a flu pandemic it would have cost many lives.

The SARS outbreak was resolved with the help of hard work on the part of many people, including heroic doctors in Hong Kong and WHO epidemiologists, one of whom died identifying the disease. Had this truly been H5N1, however, we would almost certainly have had a pandemic. This, despite even more dramatic departures from WHO's Westphalian heritage. In trying to stop the global spread of SARS, WHO issued travel advisories against the wishes of powerful member states and suffered a backlash from Canada as a result. And while WHO had made progress, SARS showed its capabilities were probably inadequate to stop a pandemic from the influenza virus.

In 2005 the IHR were officially de-Westphalianized, the culmination both of their failure in an age of global pandemics or threatened pandemics (HIV/AIDS, SARS, now avian influenza) and the "facts on the ground" regarding new actors on the global public health stage (discussed in Part III). The revised IHR don't seem up to the task, however, despite their departure from their Westphalian roots. In particular, there are many loopholes, long timelines, gaps and vague clauses, problems that to any lawyer's eyes, would vitiate the force of the new regulations.

Given the nature of this intergovernmental agency it may be as good as it can do. We don't have a world government and the US have done all in its power to circumscribe and weaken the UN, the world's only and already weak supranational force. And the revisions may prove very useful for other, regional or more localized outbreaks of disease. But it is hard to see how they will change much in WHO's ability to affect the evolution of an evolving pandemic threat from avian influenza. (You can read the IHR here and some thoughtful and heated commentary on it on The Flu Wiki in this Forum Thread. The Forum is the freewheeling discussion section of the Wiki and is separate from the "informational" side. In particular you will find useful annotations of the IHR by anon_22 at 10:35.)

If the revised IHR have any significance it lies elsewhere. In the final post, we broaden the question of where WHO fits in, not with respect to the international system, but with respect to the new global health system that includes WHO, NGOs, multinational and national businesses -- and the new communities growing up around the internet. In other words, us. This is a critical discussion we need to shape our response to the other actors who share the global public health stage with us: our own countries, NGOs, intergovernmental organizations like WHO, FAO, OIE and the World Bank, and the various internet communities that rub shoulders, sometimes cooperatively and sometimes in opposition.