Medical Examiner

WHO and the Flu

The problems with the World Health Organization’s approach to pandemics like swine flu.

Keiji Fukuda of the World Health Organisation delivers an update on swine flu.
Keiji Fukuda of the World Health Organisation delivers an update on swine flu

The World Health Organization’s FluNet, a contagion-control network, not only helps to track influenza but gives us essential knowledge of prevailing strains to help us prepare the yearly vaccine. And the WHO’s quick boots-on-the-ground response to flu has been instrumental in following and analyzing the A (H1N1) swine flu outbreak.

But at the same time, the WHO has been engaged in the kind of scary speculation that is unscientific and that creates the kind of fear backlash that has been filling the world’s emergency rooms with sniffling worriers, obstructing the treatment of others with life-threatening noninfluenza illnesses. At the height of the flu scare, a patient of mine who arrived in the E.R. with several broken bones, a head injury, and profuse bleeding was back-burnered in favor of “flu sufferers” who later tested negative. She waited for more than an hour, experiencing further bleeding and risking infection from her open wounds. She was ultimately OK, but the delay was dangerous. Although tracking the new flu was certainly in the interest of public health, the symptoms being reported didn’t warrant this kind of emergency triage.

As the number of confirmed swine flu cases in the world reached more than 6,000 this week, WHO flu chief Keiji Fukuda was busy speculating wildly at a press conference on May 7 that this outbreak could end up infecting up to 2 billion people—one-third of the world’s population. He said he based this prediction on the behavior of previous pandemics, but the 1968 Hong Kong flu, the last true pandemic, infected far fewer than that. Modern public-health practices, such as vaccination and treatment of secondary infection with antibiotics, helped partly contain the virus. It still killed 1 million people worldwide but nothing on the order of the 1918 Spanish flu, which killed more than 50 million.

Since the current H1N1 swine flu strain is mild, has had only limited outbreaks so far, and has killed fewer than 100 worldwide, it is—and was—far too early to be speculating on the extent of its spread. Further, it is likely that the death rate is actually much lower than has been reported, because most mild cases have not been confirmed. Flu outbreaks tend to wane in the summer months, as respiratory viruses appear to be transmitted more easily during periods of low humidity. It is wise to be tracking this virus into the Southern Hemisphere as that region’s winter and flu season starts, and it is wise to be preparing a vaccine. But the WHO’s tendency to make sweeping, unsubstantiated predictions is not helpful. Back in the fall of 2005, David Nabarro, the United Nations’ systems coordinator for avian and human influenza, predicted that 5 million to 150 million could die of bird flu. In the spring of 2003, the WHO, predicting a 5 percent to 6 percent death rate from SARS and concerned about a massive pandemic, issued its first travel advisory and enacted a global surveillance network. This effort cost the world’s economies more than $30 billion. In the end, SARS infected only 8,400 people, killing 774 worldwide, before the WHO finally concluded that this virus didn’t spread easily through the air.

Part of the problem exists with the Epidemic and Pandemic Alert and Response system WHO uses to warn us about pandemics, focusing attention and then ultimately asking for billions of dollars in funding. The WHO’s Global Influenza Preparedness Plan was updated in 2005 in response to the H5N1 avian flu scare. But in part because it is a response to a scare rather than a real pandemic with documented cases, it lacks any quantification of either extent of spread or severity of the virus. The current swine flu outbreak, the first time the revised flu-alert system has been used, suffers from ineffectiveness due to its vagueness and premature trigger. This is why we can be on the verge of declaring a pandemic for swine flu. The current Stage 5 (out of a possible 6) of the WHO Pandemic Alert for swine flu virus states, “human-to-human spread of the virus into at least two countries in one WHO region … while most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent.”

The word pandemic comes from the Greek meaning everyone, and imminent is another term that unnecessarily alarms us. But the biggest problem of all is the worldwide alert for a problem that is not that extensive or deadly. If this is how the WHO gears up in advance of a real problem, how can it possibly retain the resources to deal with the world’s real pandemics, such as HIV/AIDS, malaria, tuberculosis, diarrheal diseases, or malnutrition? Consider that 33 million people suffer from HIV in the world with more than 3 million deaths per year. There are 300 million to 500 million cases of malaria per year according to the WHO, with 1.5 million to 2.7 million deaths. More than one-third of the world is starving, and the WHO reports that at least 15 million children die of hunger each year.

Do we want precious WHO resources so easily diverted from these children to a postmodern panic born of our obsession with a new flu strain?