Thursday, April 15, 2010

None So Blind As Those Who Will Not Listen



# 4500




There’s an editorial today in Canada’s National Post expressing outrage that the World Health Organization continues to label the spread of novel H1N1 a `pandemic’, and castigating the WHO for not retracting the pandemic declaration (and apologizing) once the severity of the H1N1 virus proved to be less than catastrophic.


For those interested, you can read The WHO’S Biggest Mistake, although it is comprised mostly of the standard anti-WHO rhetoric that has become so popular over the past year. 


I’ll only pull one short passage – which seems to be the author’s biggest point – to discuss.


“By the time the WHO realized that swine flu was not a pandemic in the layman's sense of that word (infecting a high percentage of a population and killing a high percentage of those infected), it should have issued a mea culpa for overstating H1N1's risks. It didn't.”


And this is a curious notion indeed; that public health officials and scientists should rely on layman’s definitions when making policy or issuing advice.


While that may sound reasonable, the reason doctors and scientists endeavor to use precise scientific terms is to avoid ambiguity.  


As far as I know, there is no single popular `lay’ definition of a pandemic.   Not one that is applicable and well understood across all cultures and societies of the globe. 


The popular `lay’  perception of a pandemic – at least in the western world – seems to be based on novels like George R. Stewarts Earth Abides,  Stephen King’s The Stand, and the BBC’s production of Survivors.  


George Romero fans would argue that if it doesn’t involve zombies, it doesn’t really qualify as a pandemic.


By those standards, the status of 1918 as a pandemic would be in doubt.


Lacking a global consensus, the WHO decided they had to define a pandemic.  They chose – wisely or not – to base the definition on the geographic spread of a new virus, not on its severity.


Severity, they felt, could vary widely by economic and societal regions.  A virus that might be mild in North America could prove devastating to sub-Saharan Africa.  And the severity of a virus can change over time – sometimes abruptly.


None of this was a secret, of course.   The WHO stated repeatedly in the weeks leading up to their declaration of a pandemic exactly what their criteria was.   


That it was not based on the severity of the virus.


In fact it was pretty apparent even in May and early June that the novel H1N1 virus – while spreading like a pandemic – was less virulent than initially feared.


One of the advantages to having 4500 blogs archived on this site is we have a pretty good chronicle of the events leading up to the declaration of a pandemic.


On May 9th (see ECDC Daily Situation Reports), just a couple of weeks after news of the novel virus hit the media, I wrote :


Under the current WHO guidelines, should sustained transmission be detected in 2 or more (of the 6) WHO regions, pandemic phase 6 would be declared.


A `Pandemic’ - using the WHO’s definition and not Stephen King’s - is based on geographic spread of a new disease . . . not the severity of illness.

WHO Member States are grouped into six regions. Each region has a regional office. The map shows the WHO regions and the location of the regional offices.


This is a mantra that I, along with many others, repeated often.  Three days later (see Sunday Morning WHO Update (# 24)), I wrote:


Despite public misconceptions, severity of the virus is not (currently) taken into account when declaring a pandemic.


Just geographic spread.


There are calls, however, to change the WHO pandemic definition, to take `mild’ illnesses into account.


And you’ll find this message repeated again and again, including in:


CIDRAP: WHO Sees Problems With Pandemic Severity Index
A (New) Pandemic Primer


It was obvious, of course, that the definition of a pandemic wasn’t perfect, and there was much debate at the time over including some sort of `severity’ qualifier to any pandemic declaration.  


The problem was . . . no one could predict how severe the pandemic would be across the globe.   Countries with antivirals, reasonable health care facilities, and eventually vaccines could be expected to fare better than countries without.


The decision was eventually made to stick with the existing pandemic definition, and hope that people would appreciate that there are differing degrees of pandemic severity. 


As far as the perceived virulence of this novel virus was concerned, it was apparent long before the pandemic was declared that novel H1N1 was looking like a low mortality-high morbidity pathogen.  


A virus that killed relatively few, but sickened many.  


In late May, in  Fear Of Fluing, I wrote about the apparent low lethality of the virus.  In An Appropriate Level Of Concern I stressed the uncertainty of any pandemic predictions, and on on June 11th – hours before the pandemic was officially declared – I wrote in A (New) Pandemic Primer:


The good news (at least so far) is that this virus doesn’t appear to have the virulence (severity) that some pandemic strains have demonstrated in the past.


None of this is to suggest that this virus is benign.   It isn’t.  It is fully capable of producing serious, even fatal, illness in some small percentage of its victims.


For now, the WHO is calling this virus `moderate’not mild.


Early studies have suggested that it may be roughly equivalent to the 1957 `Asian Flu’ in virulence, but it is probably too soon to say with any certainty. 


If all of this sounds less like `panic mongering’ than some editorialists of today would have you believe, you’re right.


The appropriate words were being spoken, just too few people heard them. 


I didn’t weave all of this `moderate’ information out of whole cloth.  I was getting it from the CDC’s daily news conferences, reports from the ECDC, and of course statements by the World Health Organization.   


Regrettably, much of the media at the time conveniently ignored many of nuanced messages issued by public health officials, and concentrated on the more `marketable’ aspects of the story.


Could the WHO have done a better job in getting out this message?


Absolutely.    And that is something they need to work on. 


I literally cringed a few times last summer when listening to some of the statements made by WHO officials.  Not so much for the accuracy of what they said, but for the naiveté they exhibited by not realizing how their statements would be interpreted by a deadline (and headline) driven press.


Doctors and scientists often place more value on words like `may’ or `could’ or ‘possibly’ than do reporters.  Those nuances have real meaning in the scientific world.  


To many reporters, they simply get in the way of a good story, and are easily ignored.


But I also recognize that the WHO is hampered by the diplomatic niceties required when dealing with 200+ sovereign nations, scores of of languages, and thousands of varying cultures.


And that they ran into a buzz-saw of harsh media (and Internet) critics, driven by agendas that ranged from anti-vaccine activists to those who view the WHO as an extension of the New World Order and as a threat to their national sovereignty.


This was literally a no-win situation for public health officials from the start.  An unenviable position, perhaps, but one that the CDC and the HHS managed far better than the WHO.



The WHO could take a page from the HHS’s playbook, and look at how they utilized social media, made frequent (often daily) press conferences, and (horrors!) actually engaged in conversation with bloggers during this pandemic.


Like it or not, the Internet, social media, and an often free-wheeling press are realities that the World Health Organization must learn to effectively deal with. 



They, like the pandemic threat, aren’t going away.


Trying to find an appropriate`one-size fits all’ approach to pandemic messaging may prove impossible.  Crafting target specific messages – appropriate for subsets of the globe – may be the only real solution.


But to do that, the WHO needs to abandon the 20th century approach of issuing statements from on high, and get into the Internet trenches and learn how to effectively communicate in this new medium.


In this 21st century, one either embraces the changes brought on by our digital world, or risk being consumed by it.


Jody Lanard M.D. said...

1. Great comment re: reporters, early on and throughout, eliminating nuanced words used by experts, like "may" or "could" or "possibly."

That is exactly what allows them to later write bizarre statements like, "Remember when WHO said we were all gonna die?"

2. You stated: "Under the current WHO guidelines, should sustained transmission be detected in 2 or more (of the 6) WHO regions, pandemic phase 6 would be declared."

I routinely point out that this geographical stipulation is itself problematic.

For instance, if there is initial community transmission in Laos and Cambodia (WHO WPRO region), and then in Thailand (WHO SEARO region), that would qualify as Pandemic Phase 6 -- even though the community transmission was taking place in three small adjacent countries.

But if there is initial confirmed community transmission in Canada, Mexico, and Peru – three large countries separated by thousands of miles – that would still be Pandemic Phase 5, because all three countries are in the WHO PAHO region!

3. In June you noted: “For now, the WHO is calling this virus `moderate’ – not mild... Early studies have suggested that it may be roughly equivalent to the 1957 `Asian Flu’ in virulence, but it is probably too soon to say with any certainty.”

One problem later in the pandemic was WHO’s continued refusal to acknowledge that by pandemic standards, in developed countries, the pandemic’s first and second waves really seemed to be "mild."

In recent years, WHO’s planning assumptions (not predictions) for a future pandemic have included this statement:

“WHO has used a relatively conservative estimate – from 2 million to 7.4 million deaths – because it provides a useful and plausible planning target. This estimate is based on the comparatively mild 1957 pandemic.” (The comparison was with the devastating 1918 pandemic, of course.)

In May 2009, WHO talked about the 1957 and 1968 pandemics this way: “The pandemic that began in 1957 started mild, and returned in a somewhat more severe form, though significantly less devastating than seen in 1918. The 1968 pandemic began relatively mild, with sporadic cases prior to the first wave, and remained mild in its second wave in most, but not all, countries.”

Despite prior use of the term “mild,” WHO resisted this usage throughout the 2009 H1N1 pandemic -- sometimes based on the rationale that no one knew how bad things were in the developing world, and other times because it seemed callous to call a pandemic “mild” when it was killing more people under age 65 than usual.

But its repeated refusal to call the first waves “mild” (at least in the developed world) did contribute to the incorrect impression that WHO was “hyping” the pandemic-as-it-was, as opposed to warning about what it might become.

Michael Coston said...

Thanks, Jody.

I appreciate your insights on this.

The refusal to call the pandemic `mild' in the developed world, as you stated, would appear to have opened the door to more criticism.

`Mild' is a relative term, of course, but it does seem appropriate in this case.

Hopefully the communications missteps of the past year can be learned from, and corrections made, before the next crisis hits.

Joe Burns said...

I just have 1 question re vaccines;

"are they safe?"

let me be more specific, is it "safe" to give multiple vaccines to babies under the age of 6 months?

Can you also please define "Safe" so that there is no ambiguity, if 1 in a million babies die due to an adverse reaction to a vaccine, is that the acceptable amount of "Collateral Damage"? ie; how many babies or children need to be injured for a vaccine to be considered "Safe" or "Unsafe"?.

My own personal feeling is that vaccines are necessary but their efficacy and safety needs to be studied before giving to infants who do not have a developed immune system.

I would not consider any drug or vaccine safe if the manufacturer has being given indemnity against prosecution, although there are Vaccine Injury Compensation Boards in almost every country in the world.

I would really like to hear your views on this, there seems to be a lack of information specifically regarding infants and children on your blog, Thanks,