External review of WHO's response to the H1N1 influenza pandemic
Dr Margaret Chan
Director-General of the World Health Organization
Dr Fineberg, distinguished members of the Review Committee, ladies and gentlemen,
I and my staff are at your disposal. These staff represent the diversity of expertise involved in the response. We will do our best to answer your questions faithfully and factually.
We kept extensive records, and these are also at your disposal. Among other things, these documents will allow you to see, in the context of a rapidly evolving situation, what data were available and considered when key decisions were made.
As you know, this has been the most carefully watched and scrutinized pandemic in history. Understandably, the response of countries and WHO is also under scrutiny. To some, response measures now look excessive compared with the moderate impact of the pandemic.
We are grateful for the moderate impact. Had the virus turned more lethal, we would be under scrutiny for having failed to protect large numbers of people. Vaccine supplies would have been too little, too late, with large parts of the developing world left almost entirely unprotected.
I am, of course, alert to all perceptions of how this Organization performs, in all areas.
For the pandemic, WHO has received some praise and support from early assessments published in the medical and scientific literature, in addition to support and feedback from our Member States.
WHO has also received some criticism.
Large sums of money were invested in commodities that were not used, sometimes because the public saw no need for them or questioned their safety. The definition of a pandemic and the pandemic phases have been questioned. The clinical value of oseltamivir has been questioned. Conflicts of interest and their influence on decisions have become an issue.
But between criticism and praise is a solid middle ground.
It is in your hands to determine what worked well, and what went wrong, especially as this pandemic was the first major test of the revised International Health Regulations. It is in your hands to advise us on necessary changes in the way we coordinate the response to public health emergencies of international concern.
This review is being conducted very rigorously and taken very seriously. We trust your expertise, and thank your Chairman for his diligence.
Ladies and gentlemen,
The world was better prepared for a pandemic than at any time in history. But it was prepared for a different kind of event than what actually occurred.
Experts widely assumed that H5N1 would cause the next pandemic, and its severity was almost taken for granted. Changes in the H5N1 situation frequently made the headlines. Pandemic became a hugely frightening word in the minds of the public and the media.
This was the mind-frame when the new H1N1 virus emerged.
The phased approach to pandemic alert was introduced by WHO in 1999. The intention was to allow WHO to gradually increase the level of preparedness and alert without inciting undue public alarm. In reality, it had the opposite effect. It dramatized the steps leading to the declaration of the pandemic and increased the build up of anxiety.
I personally do not believe that WHO exaggerated the threat. When I announced the move to phase 6, I reminded the world that the number of deaths worldwide was small and that we did not expect to see a sudden and dramatic increase in this number. I stressed that the overwhelming majority of patients recovered fully without any medical care.
Managing the discrepancy between what was expected and what actually happened was problematic. Attempts to dial down preparedness plans to suit a less severe event were problematic. No one could answer, with certainty, a fundamental question. Is it safe to do so? Are we sure? Do we dare?
Though much early evidence pointed to a moderate, if not mild impact, most health officials decided to err on the side of caution.
A new disease is, by definition, poorly understood as it emerges. Decisions with far-reaching consequences need to be made quickly in an atmosphere of considerable scientific uncertainty. Flexibility to adapt to emerging information is critical.
In this regard, the phased approach to the declaration of a pandemic was rigid and confining. In communicating the level of alarm, authorities need to be able to move down as well as up.
The finite capacity and long production times of vaccine manufacturing reduced the flexibility of the response. Some countries placed large orders before data were available to support evidence-based projections of need, including the number of doses.
The public health community faced many difficult communication challenges.
We did not anticipate that large numbers of people would decide not to be vaccinated.
WHO and many countries were unprepared for a new form of scrutiny: electronic scrutiny by the public, including through social media. Today, people draw their own instant information from a wide range of sources. They make their own decisions about which advice to follow.
The public health community must urgently adapt to this reality.
As the pandemic progressed, we had great difficulty explaining why the number of laboratory-confirmed deaths, reported on our website, was not a reliable measure of the pandemic’s impact.
Many journalists and bloggers compared the number of these deaths with estimated excess deaths during seasonal epidemics, either for a country or worldwide. This led to the familiar conclusion that the pandemic was even milder than normal influenza, and supported the perception that vaccination was unnecessary.
I believe some things worked well. The International Health Regulations brought a clear set of obligations, channels of communication and coordination, and mutual accountability.
The IHR also introduced a series of checks and balances designed to ensure that no one, myself included, had unfettered power. In my view, the Emergency Committee, with both experts and affected states represented, functioned well as a balanced and inclusive advisory body.
I believe the early distribution of stockpiles of oseltamivir to developing countries was useful. In many cases, health officials could announce confirmation of the first cases together with the reassuring message that medicines were in hand to manage cases.
We did less well with the distribution of donated vaccines. They arrived, but much slower than was hoped.
I have a final remark. I was deeply involved in the discussions that led WHO to announce phase changes.
I can assure you: never for one moment did I see a single shred of evidence that pharmaceutical interests, as opposed to public health concerns, influenced any decisions or advice provided to WHO by its scientific advisers.
Never did I see a shred of evidence that financial profits for industry, as opposed to epidemiological and virological data, influenced WHO decisions.
As I said, I, my staff, and our records are at your disposal.