Wednesday, June 07, 2006

WHO, part V: end of the beginning

[This is the last post in the series about WHO (part I, part II, part III, part IV). We try to sum up where the story has (unexpectedly) brought us.]

For everyone reading this series of posts wondering where we were going, we were wondering, too. The Reveres started blogging because for us, "writing is thinking," and we believed strongly then and continue to believe now that the progressive public health movement did too little thinking and too much sloganeering. We started writing as a way of trying to think things through, doing it publicly because we beleived there was much raw brain power "out there" to help us move things forward. We haven't been disappointed, despite the occasional aggravation that goes with asking people what they think and giving them an opportunity to answer.

The WHO series originated because of our distress over criticisms leveled at WHO regarding their transparency, their honesty and their motives, especially the issue of sequence release and their incomplete recording of case data. If you read the comments here you will find us defending WHO and flu scientists and trying to parry accusations we felt were unfair and misdirected. It was our thought that one way to have a more persuasive response was to explain where WHO fit into the whole scheme of things. Hence this series.

But a funny thing happened on the way to the last installment. Our original ideas began to evolve, and we must acknowledge that some of our readers' criticisms of WHO had more force than we gave them credit for, and some of the optimism we had about WHO's own recognition of the problems has been tempered. We still have respect for the many highly competent professionals in WHO, some of whom risk their lives in the cause of public health. We still have sympathy for the extremely difficult position WHO finds itself in as an intergovernmental agency trying to work with governments whose highest priority is not the health of the world's people, or even, in some cases, the health of their own people. We still think the imputation of base motives to many in WHO is misguided, misdirected and unfair. And along with our wiki colleague anon_22, we still think we are better off having WHO than not having WHO -- by a long way. But we no longer see WHO as the principal engine safeguarding global public health.

One of the fundamental problems is that WHO, however global its vision, can act only through the same sovereign states that constitute its membership and are the instrumentalities through which any actions are taken. WHO's success in the SARS outbreak rested on its authority as a source of global alert, best clinical practice, and most dramatically, geographically-specific travel advisories. These products all depended on WHO's ability to provide information. But as the H5N1 threat has evolved in relative slow motion, old Westphalian habits hve reasserted themselves, as WHO scrambles to manage information and reveal it simultaneously. Cumulative missteps -- contradictory stories, clear spinning towards less threatening outcomes, unfounded claims of certainty and authority when uncertainty and powerlessness were the reality, lack of transparency about sequence information and case data, overstatement and understatement -- have seriously weakened the only real source of WHO power, its credibility and authority.

Three years ago WHO would have been able to weather these self-inflicted wounds. Now WHO must compete with an abundant free flow of information on the internet, information which is sometimes correct, sometimes not, but often as accurate or more accurate than WHO's. It comes from the same raw sources as WHO's but its interpretation is not bound by WHO's rules, traditions or constraints. If those rules and constraints were the source of discipline to make WHO's version superior, it would be one thing. But they aren't. They are another source of distortion. Thus one of the sources of WHO's enhanced powers after the revision of the IHR, the management of the flow of epidemiological information and surveillance, has been overtaken and perhaps made irrelevant by the advance of technology and the new social structures it fostered.

WHO's complementary role in coordinating global resources for control of local and regional disease outbreaks remains an important one, but it is moot for a pandemic which happens everywhere. There is not much ability to focus and coordinate resources that are needed everywhere. The "national system" upon which WHO depends is also clearly incompatible with the demands of reacting to infectious diseases that care nothing for national borders. For an evolving pandemic where managing the consequences is paramount, the main tool is information.

In that sphere, WHO and its sovereign member nations must not only share the stage with many non-state actors, but it must share them with actors that can rise to the demands of a pandemic better than WHO itself. WHO's epidemiological intelligence function has been superseded by a global internet that ferrets out, assembles and interprets information faster than WHO and often arrives at plausible interpretations at odds with the ones advanced by WHO.

Where does this leave us? We wish we knew the answer, but the H5N1 pandemic threat has left WHO and the world suspended in a kind of global public health limbo, recreating the anarchy of Westphalian public health but enlarging it to include all the other actors as well: states, intergovernmental agencies, NGOs, multinational corporations, public-private partnerships, and the increasingly influential world of information fed internet subcultures. Like the nations of the world, we need to find a way to work together. Information has become the currency in this world. We all want more of it and we want real gold, not fool's gold.

Information is a type of product that isn't depleted with use. It is not a counter in a zero sum game, with your gain my loss. Just the reverse. When it is distributed and redistributed, everyone gains. The lesson is that we all need to treat that resource with the greatest respect and the utmost of generosity. If WHO wants to regain some credibility and effectiveness, the single most important thing is to open the spigots of information full bore. We know it hasn't done so yet.

The same is true of my scientific colleagues. If you work on infectious diseases of pandemic importance, you will have to change your customary way of doing things. For some this is hard but it is necessary. For students and their mentors who fear this will put them at a competitive disadvantage in the academic world, that's going to be the price you will have to pay to be in this field. There are a lot of other subjects you can pursue if this is unacceptable to you. To health agencies like CDC, you will also have to provide the same kind of information, without regard for political, career or commercial considerations. It's not a choice. Do it or lose your authority and credibility. This is a constraint the outside world is placing on you.

For us, the distributed and global world of obsessed information harvesters, purveyors of hopes and fears, cassandras and hucksters, prophets and ordinary folks, there are also responsibilities. We need to practice fairness, consideration, empathy, constructiveness, and the desire to help each other and others engaged to the same ends, including WHO and CDC, in this increasingly turbulent drama against a virus that doesn't think, doesn't care and isn't even alive.

Maintaining that balance and openness ourselves may be the toughest job of all, as we struggle to push others to do their jobs, too.