Since late 2003 and the re-emergence and the global spread of the
H5N1 ‘Bird Flu’ virus, governments around the world had been preparing for another influenza pandemic. The aetiological agent that caused the next pandemic though was not the much-feared H5N1 virus
but rather a novel strain of influenza H1N1 that emerged in La Gloria, a small rural village in Veracruz,
Mexico, in March 2009. From this remote location, the virus spread worldwide within weeks, carried by international travellers to initiate outbreaks in over 200 locations worldwide (WHO 2013).
The WHO’s handling of the 2009 influenza pandemic attracted criticism both during the crisis and in its aftermath. Moreover, in response to concerns the IO had been unduly influenced into declaring a pandemic by experts with links to the pharmaceutical industry, a total of three internal and external investigations were launched into the organisation’s management of the crisis (WHO 2011; Flynn 2010; Cohen and Carter 2010). All three investigations subsequently concluded there was no evidence the WHO had engaged in inappropriate conduct. Nevertheless, each of these independent panels recommended amendments on how the IO responded to future health emergencies. While some of these measures have been enacted, in hindsight, it is now clear that there were at least two significant, related ‘mistakes’ in the WHO’s management of the 2009 pandemic: the first being the WHO’s decision to label the responsible aetiological agent ‘swine flu’ and, the second, to remove guidelines from the WHO website after a policy discrepancy was identified.
Throughout the twentieth century there was a discernible trend for naming influenza pandemics after specific countries or areas (e.g. 1918 ‘
Spanish Flu’, 1957 ‘
Asian Flu’ and 1968 ‘
Hong Kong Flu’). Such practices have, however, also often culminated in significant economic damage to locations associated with disease (Cash and Narasimhan 2000). In an explicit attempt to avoid the risk the 2009 influenza pandemic would be labelled the ‘
Mexican Flu’ (on account that Mexico was the location where the disease first appeared), the WHO secretariat initially settled on identifying the pandemic with the animal that is most closely associated with the H1N1 virus: pigs. Accordingly, for the first few weeks of the 2009 crisis, the pandemic was extensively described by the WHO and international media outlets as ‘Swine Flu’ (Cohen 2009b; Butler 2009).
The WHO’s decision to adopt the generic identifier ‘swine flu’ was arguably a noble one, intended to avoid damage to the Mexican
economy. It did, however, result in a raft of unintended consequences that rapidly revealed the decision was a mistake. Indeed, within weeks of the descriptor being applied, approximately 20 per cent of the WHO’s member states implemented a series of measures that exceeded, and thereby contravened, international norms (Davies et al. 2015). In late April 2009, for example, the Egyptian government ordered the mass culling of all pigs throughout the country (estimated to be between 250,000 and 400,000 animals) as a ‘preventative measure’, despite the fact that no human cases of H1N1 had been recorded in Egypt nor any reported outbreaks of H1N1 had occurred in pigs worldwide
(Katz and Fischer 2010). Within days, the Iraqi
government followed Egypt’s lead and ordered the culling of three boars in a Baghdad zoo (Karadesh 2009). Added to this, some 20 other countries including
imposed trade import bans on all live pigs, pork and pork products, citing concerns over the risk that H1N1 may be introduced into their respective human populations (Lynn 2009; WTO 2009; Katz and Fischer 2010).
Quickly recognising the unintended consequences of the ‘swine flu’ label, the WHO secretariat launched a campaign to re-brand the pandemic ‘influenza A(H1N1)’ and co-opted other IOs to assist in halting the various bans and related measures. On 26 April 2009, for instance, the organisation issued a press release that emphasised that trade and travel restrictions were not recommended (WHO 2009e). The next day the secretariat expanded on this, unequivocally stating, ‘[t]here is also no risk of infection from this virus from consumption of well-cooked pork and pork products’ (WHO 2009f). On 29 April 2009, a representative from the Food and Agriculture Organization (FAO)
SeeSeeFood and Agricultural Organization
went further, explicitly condemning the Egyptian government by describing the slaughter of the country’s entire pig population a ‘real mistake’ and stating ‘[t]here is no reason to do that’ (Stewart 2009). To add further weight to this public messaging, the next day, the
FAO, WHO and the World Organization for Animal Health
issued a joint statement stipulating that pork and pork products were safe and that trade bans were unwarranted (FAO/WHO/OIE 2009). This statement was then re-issued on 7 May 2009 to further reinforce the message (Ibid). Nonetheless, several countries persisted in applying live pig and pork import bans with the result that official complaints were formally lodged with the World Trade Organization (WTO)
SeeSeeWorld Trade Organization
in late June 2009 (WTO 2009).
Throughout the subsequent WTO
hearings and other forums, most governments acknowledged that the import bans and related measures had been implemented without any scientific basis. They had done so though, primarily due to the initial correlations that had been drawn by the WHO between the virus and pigs. For instance, when challenged in the
WTO, the Chinese government sought to justify its actions on the basis of ‘its huge population, its susceptibility to the disease through human-to-human transmission, the fact that China
was the world’s biggest producer of pork and that pork was the most consumed meat product in the country’ (WTO 2011: 4). Similarly, when questioned about their decision to slaughter three wild boars, a representative from the Iraqi zoo admitted that their actions were not based on science but were rather designed ‘to break a barrier of fear’ amongst zoo visitors (Karadesh 2009). The
Philippines, which had banned pork imports from the USA, Mexico and Canada in late April 2009 as a ‘precautionary measure’(Joshi 2009), lifted the ban within a week for the USA
SeeSeeUnited States of America
but sought to justify their continued ban on Canada
on the basis of a suspected case of swine-to-human H1N1 infection (Ager 2009).
What these statements reveal is the critical importance of appropriate public health messaging at the outset of a health emergency. Although the WHO secretariat had attempted to avoid the risk the 2009 H1N1 influenza pandemic would become known as the ‘
Mexican Flu’, by selecting an alternative descriptor, the organisation had inadvertently instigated harmful trade and animal welfare practices. The fact that there was no clinical evidence of the 2009 H1N1 virus spreading between pigs and humans proved irrelevant; the damage had been done by drawing the correlation between pigs and the virus. Compounding the WHO’s mistake, a small number of countries took the additional step of quarantining Mexican citizens in their respective countries, or prevented travel to and from
Mexico, in an inept attempt to limit the virus’ transmission. Although conceivably it could be argued the proportion of countries that engaged these latter measures was potentially smaller given the IO had acted so precipitously to negate the association being drawn between H1N1 and Mexico, it nevertheless proved only partially successful. In hindsight, therefore, it can be appreciated the IO’s initial descriptor was not only a mistake that could have been predicted and easily avoided by selecting an alternative name (such as ‘H1N1’), but it also failed to comprehensively repudiate an association between Mexico and the H1N1 virus (and the associated economic repercussions) that was
Removal of Pandemic Guidelines
Like many disease outbreaks before it, the 2009 H1N1 influenza pandemic was characterised by much uncertainty. Fortunately, due to the work undertaken post-2005 in strengthening pandemic preparedness through increased disease surveillance and collaborative arrangements, the epidemiological agent responsible for the crisis was rapidly identified as a novel strain of influenza. Importantly, however, it took a number of months after the disease’s identification in April 2009 before the lethality of the virus could be accurately determined. Concern over the severity of the virus and the risk to communities was also exacerbated by international media reports, particularly in the initial weeks; until sufficient data had been gathered and interpreted, it was unclear what measures were required to contain the disease and prevent unnecessary human morbidity and mortality.
It was within this context that the WHO perpetrated its second notable mistake during the H1N1 pandemic: removing its own pandemic influenza guidelines from the organisation’s website. Since 1999 the WHO had actively encouraged countries to strengthen their pandemic preparedness and had released a series of guideline documents that detailed various measures designed to achieve that objective (i.e. building vaccine manufacturing capacity, stockpiling antiviral medications, developing national emergency committees, etc.). These guidelines were also important as they introduced a framework for how and when a pandemic would be declared by the IO, outlining the multiple stages and decision points (described as ‘phases’) such as ‘limited human-to-human transmission’ through to widespread, sustained community-level infection (WHO 1999a, 2005, 2009c). Somewhat ironically, the WHO secretariat had released the latest version of these pandemic influenza guidelines only a few months before the first recorded outbreak of H1N1 in
Mexico. One of the crucial factors cited in the most recent version of the guidelines for declaring a pandemic though had been an assessment of the severity of a virus.
The first recorded cases of H1N1 were officially reported to the WHO by the US Centres for Disease Control and Prevention
on 18 April 2009. Within the week, further cases had been confirmed in
Mexico, including several clusters of young and previously healthy adults contracting severe pneumonia (WHO 2009g). By late April, Mexican
health authorities had obtained reports of infection rates around 50 per cent in some areas (Ibid), with over 1300 suspect cases and approximately 84 probable deaths (PAHO 2009). Within days, laboratory confirmation was obtained that localised outbreaks were occurring in at least 9 countries (WHO 2009a), and by mid-May, the WHO had obtained confirmation of over 5000 cases throughout 30 countries in the Americas, Europe and Oceania (WHO 2009b).
Confronted with irrefutable evidence on the geographical spread of the virus, the WHO convened an emergency committee under the authority of the
SeeSeeInternational Health Regulations
International Health Regulations (IHR) to assess the data and make recommendations on whether a pandemic should be declared. On 29 April 2009, the IHR
emergency committee recommended the director-general raise the alert level from Phase 4 (community-level outbreaks)
Phase 5 (sustained community transmission), which was promptly actioned. According to the WHO’s guidelines though, the declaration of Phase 5
was also intended to send ‘a strong signal that a pandemic is imminent’ (WHO 2009c: 25).
The elevation of the alert level to Phase 5
was immediately queried by a number of critics, principally because the epidemiological data increasingly suggested that the H1N1 virus caused only mild illness in the majority of cases. In fact, by early May 2009, although there were a number of suspected deaths, only 61 H1N1-related fatalities had been verified by laboratory testing, with most infected people experiencing symptoms that were more akin to a seasonal variety of influenza (WHO 2009b). When then asked by a CNN reporter to explain the decision to declare Phase 5
in the light of the fact the WHO had previously maintained a pandemic entailed large numbers of human fatalities and severe illness, the response of the secretariat was to delete its guidelines from its website (Cohen 2009a).
The erasure of the pandemic guidelines—presumably by a member (or members) of the IO’s secretariat that lacked insight into the potential consequences that would arise—understandably created additional confusion around the WHO’s decision to declare H1N1 a ‘pandemic’. In an initial attempt to deflect criticism of the secretariat’s actions, rather than accept it had erred in its dealings with the media and accept that its removal of the guidelines was wrong, a WHO official responded to questions about the inclusion of severity criteria in the now-redacted version of the document as an ‘error’ (Flynn 2010: 9). As preparations for the annual World Health Assembly (WHA)
SeeSeeWorld Health Assembly
got under way in May though, disquiet about the secretariat’s behaviour grew. Assessing a more robust response was needed, the WHO director-general convened an urgent high-level consultation immediately prior to the WHA
to review the data and processes used by the secretariat and IHR
emergency committee (WHO 2009d). Even so, throughout the
WHA, political pressure continued to build for the IO to revise its procedures for declaring a pandemic (SooHoo 2010). The momentum was such that the director-general concluded it was necessary to appoint an independent panel to review the organisation’s management of the crisis and give the panel unfettered access.
At the same time as the membership of the independent panel was being agreed upon, a further related scandal hit the WHO when it was revealed the secretariat refused to release the names of the IHR
emergency committee members. In late 2009, a Danish newspaper alleged that members of the IHR
emergency committee that advised the director-general received financial support from pharmaceutical manufacturers. The accusation further reinforced governments’ earlier concerns by insinuating that the director-general had been improperly influenced into declaring a pandemic. Attempting to deflect this latest controversy, senior WHO officials initially publicly advocated that shielding the identities of the IHR
emergency committee members was ‘to protect the committee from outside influences’ (Cohen and Carter 2010: 1278). The argument was not sufficiently persuasive though, given the allegations had raised concerns over perceived conflicts of interest. As a result, two further external independent reviews were launched by the
Council of Europe and a joint investigation by the British Medical Journal (BMJ)
British Medical Journal
SeeSeeBureau of Investigative Journalism
Bureau of Investigative Journalism (BIJ). In early June 2010, these investigations handed down their findings, provoking the director-general to issue a strongly worded statement refuting the allegations that had been made and reaffirming that ‘[t]he world is going through a real pandemic. The description of it as a fake is wrong and irresponsible’ (WHO 2010).
All three investigations—the independent WHO panel, the
Council of Europe and the
—ultimately concluded that while transparency in the WHO’s processes needed to be improved, there was no evidence of improper conduct or undue influence. All three panels did recommend extensive procedural changes to how the IO managed future health emergencies, and the director-general agreed to implement those recommendations that were within the secretariat’s power, such as making the identities of the IHR
emergency committee members public. Even so, as discussed below, a number of the more substantive changes to how the WHO functioned during health emergencies such as the creation of a health emergency contingency fund (HECF)
SeeSeeHealth emergency contingency fund
were not implemented due to resistance by member states or inadequate resources, and this in turn was revealed to have adverse impacts on the organisation’s management of the next major health emergency: the 2014 Ebola outbreak in