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Sudeepa Abeysinghe, Pandemics, science and policy. H1N1 and the World Health Organization

Jean Andris
Pandemics, Science and Policy
Sudeepa Abeysinghe, Pandemics, Science and Policy. H1N1 and the World Health Organisation, Palgrave Macmillan, coll. « Palgrave Studies in Science, Knowledge and Policy », 2015, 243 p., ISBN : 978-1-137-46719-5.
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1The World Health Organization (WHO) is in charge of the monitoring and reporting of threats of infectious diseases and coordinating global response. More important, it is the only organization in the world responsible for the declaration of the ‘pandemic’ (worldwide) nature of an epidemic. But how did this structure manage the last pandemic of influenza, qualified as such by WHO’s own experts? This question has been subject to debate and in this particular case the notion of ‘pandemic’ seems to have been the result of a social construction rather than a scientifically based choice.

2Through an analysis of statements and documents from the time of the pandemic, Sudeepa Abeysinghe seeks to understand how this could happen, how the H1N1 pandemic was constructed, and how its management became vulnerable to criticisms from outside observers and structures, including the Council of Europe. It also explores the social and institutional structures which formed WHO’s approach and tries to explain why WHO itself became fragile after this episode.

3One of the reasons was the scientific uncertainty about H1N1. There are other simultaneous reasons such as the institutional, mandatory pathway for the decision and a shift in the role of certain other institutions concerned with public health. For a scientific fact such as a pandemic to be established, the certainty and stability of the notion have to be determined. In this case, this was the WHO’s role, but from the outset of the problem, a clear consensus on the name of the pandemic was lacking and a comparison with historical pandemics was not made. WHO failed to demonstrate that the new epidemic fulfilled the characteristics of a pandemic, the first step in a process which specialists call ‘translation’. Translation is the way by which a theoretical concept comes into existence in the field. Thus the concept of H1N1 pandemic remained poorly defined.

4After this conceptualization, a first network of players involved in the concept being questioned has to be built. Then comes the second phase, called ‘interessment’. This is the presentation of the problem to outside players. While the process further progresses, the international institution has to recruit other players, such as the national governments, for example. This is the so called ‘enrolment’ phase which, in this case, did not occur. The last phase of translation, which – mobilization – can occur when the developed network of players has been stabilized and can act in an uncontested manner. Since the previous phases of the translation process had not been conducted correctly, the last one could not be achieved with the result that the entire process remained open to criticism.

5Let us go back to the notion of « pandemic ». In the early documentation of the term by WHO, a pandemic was depicted by a number of distinct features. But in part, these assumptions were inadequately articulated by the WHO representatives. In this debate, the notion of pandemic progressively shifted from the initial characteristics to those of novelty, mutation, spread, disease activity and finally unpredictability, as outlined in the speeches of Dr Chan, director-general of the WHO. At the same time, other statements of some co-workers of the WHO were immediately retracted, adding confusion to confusion. Also the attempts to distinguish between seasonal influenza and pandemic were confused and unconvincing. Thus the narrative on the origin of the epidemic was confused, although specialists know it is very important for a successful mobilization of the players. And the same was true concerning the name of the disease, which is also very important for its characterization.

6To translate H1N1 as a legitimate threat, WHO needed to mobilize an effective discourse around the emerging network of players. This also failed. Moreover, the author refers to the so called ‘co-production’ theory, which means that de-production of knowledge has to be made in dialogue with non-medical authorities. In medicine, when speaking of risk evaluation, this co-production exists because medicine is involved with people, says Abeysinghe. In addition, some concepts, such as the severity of the disease, were not well defined at the beginning of the narrative and their definition changed over time. Also, the European Centre for Disease Control (ECDC) did not agree that the disease should be qualified as severe, although this was a precondition for a pandemic. This was an untenable strategy – or no strategy at all! Facing this discrepancy between the different opinions, WHO tried to abandon severity as a criteria for the definition of a pandemic. This also added confusion to confusion. Indeed the uncertainty made the management of the crisis more difficult, as the ECDC interpreted it as an indicator of low risk.

7It was the same concerning statistics: because they were collected by numerous countries with different methods, WHO considered them to be unusable. In fact it had no precise figures concerning the number of infected people and how many people died. Moreover, WHO categorized the flu pandemic into six phases, presumably useful as signals for the level of alert and as a basis for the action of the different national health authorities. But again these phases were poorly defined, opening, according to Abeysinghe, an ‘avenue for the condemnation of WHO by other global players’. One of the main problems was the priority given to the spreading rather than to the severity of the disease. Finally, as the different phases of the progression of the disease were not well defined, the end of the declared pandemic was also unclear as a concept and constituted a source of criticism. Facing disapproval again, WHO attempted to redefine the phases of an epidemic, but many discussions occurred about the question of severity. Yet again, this added confusion and criticism to confusion and criticism.

8The next step was prevention. Some countries and non-governmental organizations considered that WHO gave too much importance to vaccination and didn’t sufficiently emphasize other measures such as hand washing, border control, the use of antivirals, etc.). The WHO’s approach can be ‘historically’ explained: it was the way the institution had previously succeeded in a similar mission and was in conformity with the institution’s procedures as used, for example, against smallpox. Nonetheless, in the case of H1N1 flu, some arguments suggest that other measures, such as taking antivirals preventively, could be at least as efficacious as vaccines. But promoting vaccines as a primary prevention tool at the world level meant that manufacturers had to be implicated. Not only enormous quantities of vaccines had to be produced but also these vaccines had to be ethically and equitably distributed. And WHO had no authority over manufacturers.

9Another question arises about the safety of vaccines. WHO had difficulty in explaining the regulatory measures set for the control of the safety of the production of the vaccine, which was being produced using new technologies. In fact most of the arguments in favor of the safety of those vaccines were retrospective. But one of the major preoccupations was the Guillain-Barré syndrome, about which there was some concern during previous campaigns of vaccination. WHO argued that it did not represent a matter of interest, and disregarded all other measures. In the face of this attitude, the Council of Europe criticized the WHO for its management of the crisis.

10Another major criticism was made by several scientists and the Council of Europe: on epidemiological grounds they argued that this H1N1 epidemic was not a pandemic. So WHO’s characterization of H1N1 as a pandemic was unjustified and ‘unscientific’: a key failure on the part of the institution. In particular, WHO presented an inflated account of the risk. The so called ‘precautionary principle’ could be invoked, but again the Council of Europe contested the way it was used because it could create enormous fear among the population. Finally, by recommending massive vaccination for a disease which was finally really mild, WHO weakened the people’s trust.

11Because different countries made different decisions, the impact of the various measures can be evaluated. Thus the Council of Europe could see that those countries which didn’t spend large amounts of money on vaccines were not sicker than those who bought millions of vaccines.

12WHO presents itself as a kind of ‘general manager’ of global health. Although it has been contested by some individuals and organizations, it is true that we are in a globalized world. Therefore, a ‘general manager of public health in the world’ can be justified. However, the fact that nations can cede considerable power to global players while remaining accountable to their own citizens for the actions undertaken may be the source of major conflicts between international and national institutions. On the other hand, globalization induced a shift from ‘international health’ to ‘global health’. This shift reflects wider structural changes. It implies that not only national players but also intergovernmental players and non-governmental players become involved. This modified the structure of WHO as well as its way of working. Its authority was weakened and it became a facilitator rather than a leader. In this sense the H1N1 crisis played a pivotal role and highlighted neglected public health as a global problem.

13This also modified the role of the country or state because the globalized nature of the spread of infectious diseases diminishes the capacity of governments to manage them within their own borders. Again it created tension between the international health paradigm (sum of the actions of individual states) and the global health paradigm (coordination by WHO). Globalization can indeed lead to a tendency to reinforce the boundaries between the developed and developing worlds. WHO had the mission to ensure that no one was left unaided simply because they lived in a country without the means to protecting themselves. This became a source of conflict since some countries refused entry to people coming from contaminated regions of the world.

14The book is a very careful and critical analysis of the events. And according to the conclusion of Abeysinghe, these observations could teach us many things about other types of global threats such as climate change, food scarcity and so on. We would like to make one small remark: perhaps the author overlooked the remarkable efforts made in many countries for preventing contagion. It was the first time, as far as we know, that such precautions were taken at such a level in the world. It could be – at least partially – an explanation of the absence of further spreading of the H1N1 epidemic.

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Jean Andris, « Sudeepa Abeysinghe, Pandemics, science and policy. H1N1 and the World Health Organization », Lectures [En ligne], Les comptes rendus, 2015, mis en ligne le 29 octobre 2015, consulté le 22 août 2019. URL : http://journals.openedition.org/lectures/19311

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Jean Andris

Medical doctor, former researcher at the faculty of medicine of the Université catholique de Louvain (UCL, Belgium) and former lecturer in gross anatomy and physiology at the Haute École Léonard de Vinci (Academy of Louvain, Belgium). Master in history (end of studies dissertation on forensic medicine in the XIXth Century). 2013 Laureate of the Société rrançaise d’histoire de la médecine.

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