Dr. Chan and WHO on bird flu

Dr. Asamoa-Baah and Dr. Margaret Chan were two of the strongest supporters of WHO communication officer Dick Thompson's intense year-long effort to develop WHO's draft Outbreak Communication Guidelines.

In 2004, this effort culminated in a three-day meeting in Singapore at which ministry of health and WHO officials from all over the world (including Drs. Asamoa-Baah and Chan) debated and then supported a final version of the guidelines. (at http://tinyurl.com/fl9wb )

That was a major achievement for those three determined officals. Now they have to struggle to live up to the guidelines, and to get others to do so.

Revere, I know you will continue your sometimes sharp criticism of WHO, but I am so glad you took time out to underscore Dr. Chan's superb judgment in appointing "A.B.," as those of us who know him call him.

I visit other blogs about avian flu, some more anxious than yours, and I do get caught up in the fret-fest. But, Revere, I always visit your blog to be reeled back in to a more balanced frame of mind.

Your post on Chan is a perfect example. Thank you.

The analogy between the World Health Organization and the 'Wizard of Oz' is appropriate.

They have no power or influence to make a difference in the matters at hand...they are just a bystander.

My opinion of the World Health Organization was in part formed in the train wreck of SARS in Toronto, Ontario, Canada in 2003.

Observing completely preventable devastation unfold to affect the bravest and brightest of a community does not allow the giving of an inch in respect to history again repeating itself, a short three years later.

I would suggest that the WHO drop the pretense and tell the truth about their capabilities.

Tom: Exactly what was your interpretation of SARS in Toronto? The recent report seems to suggest it was the fault of the Canadian gov. What about WHO's capabilities is misrepresented and where?

The World Health Organization knew about it for months...but we were not told of the existence of an acute atypical novel pneumonia until nine days after it had been circulating in Toronto emergency departments and hospitals.

Has the World Health Organization ever apologized, even once to the doctors and nurses and others who died as a result of their gross incompetence...

...and by the way, where are the World Health Organization reports on the chronic sequelae in patients who were infected with SARS...what is their excuse for this?

...and where are the reports by the World Health Organization on the chronic sequelae of patients infected with H5N1?

Tom: Your evidence for this? If you have ever been in the midst of an outbreak it is not so clear what is going on. As it is, the Canadian gov. was bullshit with WHO for issuing a travel advisory for Canada. Does Ontario bear no responsibility here? Frankly, your rendition of the timing doesn't sound right to me. Did you read China Syndrome for an account of what happened in China and WHO's role? Just what informatioin are you relying on for your accusations? I'd also like a cite to the Canadian publications on sequelae. I assume there must be some since they are in a much better position to provide them than WHO, which is not a clinical organization or even one that has any executive powers. The same for China.

It seems to me you have a huge chip on your shoulder re:WHO and no amount of information is going to remove it. They have made mistakes, but that's not news. You try to do better and you hope others will help you to be better.

There are a lot of things WHO hasn't done, like produce a vaccine or antiviral for H5N1. That's because that's not what they can do.

Revere. As always I respectfully disagree with you.

I have a question...

What do you think of diplomatic immunity at the United Nations...and what do you think of diplomatic immunity in the contest of a regulatory agency?

...and by the way, I have been the only one standing in an outbreak many times in my professional life...I know exactly what it feels like.

Tom: Regarding your experience with outbreaks, think back on them. Maybe your experience is singular in that regard, but usually you don't know what the hell is happening at first. About diplomatic immunity, I know nothing about it and have no views on it. I imagine UN personnel have it but I don't know.

Tom I dobut if you are wrong about WHO and their mishandling of the Chinese during the SARS outbreak. It was a VERY near thing even at 10% mortality. I agree with you if for no other reason than Aunt Margaret stewed for two weeks as a "CANADIAN" citizen (she holds a Canuck passport) while sitting in HONG KONG as their chief medical type and bitching about the SARS name being coincidental with the initials for the Special Administrative Region which was being born at the time... Kind of like GRID with gays and AIDS. So we screwed around with a name for how long for both while people were dying?

Then there are the Chinese themselves who I trust as much as the French. With them its always about the appearances rather than the facts. AI is running amok over there and every country on their periphery is breaking with it but the Chinese. Politically incorrect. One thing that is clear and that is that the UN is a powerless body now funding more powerless bodies such as the FAO and WHO. They are so politicized that anything productive will fall by the wayside in lieu of that and will accelerate what I think shortly will be the end of the UN as we know it.

The WHO can reform itself for sure, just as the UN could. We spend billions of dollars (now theres a UHC program payment) with the UN each year and we get short shrift for the money. Its like paying someone to flail you. Personally, I think that we should pull out and form a NATO type of UN and let those that would join it understand that there will be teeth in screwing with an internal member or from outside. Common good for a change rather than commonly knowing that something is going on behind the scenes to stick it to another member. E.g. the French selling Hawk missile battery parts to Saddam and Iran, and oh by the way the Tripoli Six. Give them back or it wont be F-111's this time. If everyone is on the same rulebook and there is a policing of it, then yeah Revere would get his UHC with my blessing. Chan has a huge problem. If they blow this particular bug adventure then IMO there will be wars and rumors of wars. Big wars.

How do you feel about the World Health Organization having the same level of diplomatic immunity afforded to members of the United Nations?

Tom: They are UN employees. I have no particular views on it.

Randy I haven't been keeping up to date, do you mean to say we've paid our U.N. dues recently? ...Last I heard, we were years in arrears.

I don't know why you mistrust the French. All they've "done to us" recently was try to tell us invading Iraq was unnecessary (on the reasons it was being sold to us at the time, anyway), and would not go well. And hey, they were right.

If you're comfortable with us invading and occupying a sovereign nation to take their oil, more power to you, at least you're honest about it. But I remind you that that was not why we were told we were going to war we were explicitly told it wasn't and it was not the argument most people of your political stripe were making in 2002 and 2003. Frankly, I think it would have been a lot less successful in convincing the U.S. populace than the imminent threat/WMD bs.

Well, how do you feel about members of a regulatory agency that are immune from prosecution?

You and I are more then likely, members of regulated professions, whose every action is governed by a strict set of ethical parameters...

...and if someone has a complaint, there is a place for them to register their complaints and have a fair hearing. There are real consequences of these hearings.

With respect to the World Health Organization. They act with impunity, without retribution or consequence...financial or professional.

You don't get excellence and integrity by removing all forms of responsibility...in my opinion.

Tom: WHO is not a regulatory agency. They are an intergovernmental agency in the UN system, nothing more, nothing less. They have no police powers or powers of enforcement. They operate only with the assent of their member states. They certainly are subject to financial constraints. The US regularly fails to pay their dues and so can any other state. They do not act with impunity. Massachusetts General Hospital in Boston I believe has a bigger budget than WHO. MGH acts with impunity. WHO doesn't.

Revere.

The World Health Organization doesn't act with impunity?

Well, it seems to me that they were complicit in a cover-up three years ago and they are presently involved in another cover-up...as it happens both times concerning China.

They had options then and now and you and I know it...because we have been around the racetrack a few times and know how to get around bureaucracy, in the public interest.

Was SARS little matter of consequence?...well, I could take you to the homes of 100-150 persons in Toronto (those that died and those that survived and are crippled) that might tell you otherwise.

And now we face H5N1...a little thing with the potential for 65% attack rates and 10% mortality and 10% chronic life-long, life-limiting sequelae...and ten percent death from collateral damage.

Well, if the emperor has no clothes then he should damn well admit the fact and get out of the way...

...rather than pretending, putting on airs

...pretenders are dangerous...they provide a false sense of security...and in the end do more damage then good.

Impunity is ignoring regulatory medicine, ignoring science, ignoring the scientific method and ignoring scientific ethics concern...thumbing your nose at the world scientific community without explanation or apology.

Tom: Just repeating charges doesn't make them true. If you have particulars here you should tell us what they are. Maybe there are things I don't know about or maybe some of those things aren't correct. We can both learn. But just shouting at them isn't of much help.

Tom if you want the WHO - and other UN bodies - to be more effective then the answer is to give them more power and pay your dues. The US is the main stumbling block to the UN & WHO as it is the ringleader in bashing any kind of international body that does not do exactly what Washington wants, it hates any forum that might disagree with e.g. suggest it might be better to wait for Hans Blix's report on WMD before going Rambo.
France's crime was to consider using its veto agains the US's wishes in the security council, the US on the otherhand is far the greatest wielder of the veto even taking into account most resolutions never get to a vote because everyone else knows there is little point as the US will veto anyway. The US is way out step with the rest of the world on virtually any issue - check out PIPA or GlobeScan sites for polling data on how the world views you.

Revere. I wasn't yelling...and I don't think calling them pretenders is a charge, it is a fact as you clearly explained in your post at 2:37.

As you might have noticed, I have not made one comment in reference to any sovereign regulatory agency in the United States. The reason I have not is because I do not pay their wages and therefore would not comment.

However, I do contribute to the wages for 'Comical Ali' and the rest of the Keystone Cops that disguise themselves as a regulatory agency.

I guess my last question would be...do you think it would be ethical for them to be required to devulge their interest, if there is any, in Roche or other pharmaceutical companies they may be promoting...

and do you think cases where former supervisors could be lobbying those they hired and/or promoted in the past... should be disclosed as well?

Dick Thompson is in public relations for the World Health Organization. I am quite sure that his appointment book is not full, most days.

Anytime he wants to leave the 'bunker' and discuss the situation in a forthright manner according to scientific principles...I as well as other interested parties will be waiting.

Thanks as always.

Tom: Once more: they are not a regulatory agency. Dick Thompson is a press officer, not a scientist. I am not aware that anyone at WHO has stock in Roche. Are you? Finally, WHO does far more than bird flu (where there performance I agree has not always been great). Most of what they do has nothing to do with bird flu. Are you also critical of those things? Or is it just bird flu and SARS? Your government has a sorry record on asbestos but a good record on many other things. We all can improve, the US more than most (because it has more resources and potential than most).

Tom,

No one inside WHO pushes harder for WHO transparency than Dick Thompson.

And I can't think of anyone there who works longer hours.

Revere doesn't know this personally, but he can vouch for the fact that I do.

I do not expect to convince you, Tom.

But I am curious: what evidence would persuade you that WHO does NOT owe Toronto an apology? I can't find any evidence in support of your unusual position.

The WHO spokesman on influenza, Dick Thompson, told a news conference in Geneva that the WHOs official estimate of the number of people who could die was between two million and 7.4 million.

There is obvious confusion, and I think that has to be straightened out. I dont think you will hear Dr Nabarro say the same sort of thing again, Mr Thompson said.

Story from BBC NEWS: http://news.bbc.co.uk/go/pr/fr/-/1/hi/world/asia-pacific/4292426.stm

Published: 2005/09/30 15:21:25 GMT

© BBC MMVI
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Path Forward.

Would you explain the above for me. Thanks.

I cannot explain it to you, Tom, but I can tell you what might have helped mollify people who feel as you do:

WHO should have been explaining, every step of the way, that "2 - 7.4 million" was an estimate based on a very mild pandemic.

WHO should have acknowledged that it gave a misleading impression by using "2 to 7.4 million." (And apologized for doing so.)

The UN should have acknowledged that it also gave a misleading impression when it said, "The work done on prevention and preparedness over the next few months would make the difference between, for example, whether the next pandemic led in the direction of 150 million or in the direction of 5 million." (And apologized for doing so.)

It was a bad day in the annals of risk communication, starring two people who are usually great communicators.

But the causes of world outbreak transparency and pandemic preparedness have been advanced enormously thanks to the fact that neither of those two talented UN officials -- the "2 to 7.4 million" guy and the "5 to 150 million" guy -- got airbrushed out of the picture for using some misleading numbers in the fall of 2005.

If Dick Thompson is only a press officer, doesn't it seem odd that he would insult the intelligence of Dr. Nabarro...who is in fact, highly respected with good reason.

This seems like a very odd statement for a Press Officer.

You could have no idea, how much damage that same statement consistently delivered by Dick Thompson for ten months did. In my country, it was used as an excuse for inaction by Governments and Agencies...why should we prepare? It's only going to be a mild seasonal influenza type thing anyway?

At the same time as Dick's 3-7 million, I was quoting 10% mortality and got laughed out of the room.

That series of statements over a long period of time, by our harmless and hardworking press officer, will have consequences...probably big consequences.

But to be honest, you wouldn't have the pleasure of my company, if Dick hadn't made the statement.

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Path Forward.

Do you think that the World Health Organization should be given full diplomatic immunity?

I know from personal experience exactly how much Pan Prep progress was made in Canada during the "2 to 7.4 million" communication era (pun intended).

Canada made intense and remarkable progress between February 2004, when it issued a draft pandemic plan, and autumn 2005. And lots of progress since then.

Sorry, don't know anything about diplomatic immunity. Never got above the light blue Laissez-Passer level.

I hope you find the information you are looking for.

Speaking as someone who isn't really on the inside with the Canadian medical system, but who has had lots of experience observing it up close and personal, I agree with Path Forward that the Canadian government has done an astonishing job doing pandemic preparedness and public information, as they always do. Information suddenly became available on the fantastic Canadian government websites (I can't praise that Uniform Look and Feel policy too highly!), and literature started going out. There's a brand new PSA campaign specifically about handwashing, targeted in high-risk areas like public transit.

Of course Ontario should take some of the blame for what happened during SARS, but the general consensus seems to be that it could have been much worse than it was, and that the procedures that were developed and put in place quite rapidly (in the entire province) helped prevent SARS from spreading outside of Toronto. I live close enough to Toronto for my hometown to have been easily within the "first hop" of outward-radiating infection spread, and I'm glad it stayed put, personally. Interestingly, the procedures that changed because of SARS have never changed back -- people with respiratory infections appearing at ERs, Urgent Care clinics, and doctor's offices, are required to mask up, sit in isolated areas, and sterilise their hands on arrival, which may in fact go a long way towards helping prevent the spread of pandemic influenza ifwhen it actually appears.

Path Forward.

"I know from personal experience exactly how much Pan Prep progress was made in Canada during the "2 to 7.4 million" communication era (pun intended)."

I am glad that you were impressed with Canada's pandemic preparation during the 2-7.4 million communication era. Many who have had long experience with Canada's regulatory agencies were not, with good reason, but that is not what this debate is about...is it?

"I hope you find the information you are looking for."

Another interesting statement. Well, thank you Path Forward. I wasn't in fact looking for information but if I am looking, I know exactly where to find it.

Is that polite enough? /:0)

The following refers to Hong Kong, but the implications for Canada should be obvious.

btw, How is DG Chan doing on getting the sequences from Shi the soldier?

From an article published by Simon Lee. The article is no longer online, but you can find the text here:
http://tinyurl.com/2eqddc

Posted by AnnieB � at 19:43 on the old FW.

-----------

Take the Sars outbreak of 2003. Dr Chan was then chief health adviser to the Hong Kong government and responsible for determining strategy. Although the outbreak came to an end fairly swiftly, it killed a total of 298 people in Hong Kong.

A subsequent enquiry by the Hong Kong legislature concluded that Dr Chan's response to the Sars outbreak was unsatisfactory, condemning her for not attaching sufficient importance to soft intelligence on the epidemic and not taking account of the heavy passenger flow between Guangdong and Hong Kong.

If Dr Chan had announced the epidemic in Guangdong in the two months before the outbreak arrived in Hong Kong, hospitals would have had time to prepare. Instead, Hong Kong's hospitals acted like an incubator for the disease before it spread out into the community.

More egregiously, Dr Chan spent the vital early days of the outbreak wrangling with the WHO over its choice of the name for the disease: Sars.

This choice was coincidentally similar to the official abbreviation for Hong Kong, the Special Administrative Region (SAR). Instead of immediately setting in train the necessary procedures to tackle the outbreak, Dr Chan wasted time trying to save China�s face by protesting against the name Sars.

Without this delay many lives could have been saved.

Dr Chan�s handling of avian flu in Hong Kong was equally inept. When the H5N1 virus was first identified in 1997, nobody knew if it could spread to humans. Dr Chan sought to reassure a jittery public by declaring, I eat chicken every day.

However, as it emerged that poultry were dying in great quantities, the Department of Food Hygiene decided to intervene before a crisis developed. Even though Dr Chan had famously told everyone to carry on eating chicken, the Hong Kong government slaughtered approximately 1.6 million and banned all chicken imports.

So it was actually the head of the Department of Food Hygiene who took the tough decision that risked embarrassing Beijing. Dr Chan, meanwhile, was more concerned about saving her boss�s face than with protecting public health.

JJack, no Frances crime was to be selling them illegal materials banned under the UN Resolution and they got caught. Hans Baby confirmed WMD's such as VX, SARIN, and a few other nasties including bio but no nukes. Is a bioweapon a defensive weapon? Hmmm. As for the Frenchies they were sending contraband to Iraq and they continued right up until the invasion. All the did was list it by number and left it to the US and others to figure out. THOUSANDS of numbered parts. Many including gas centrifuges which have but one purpose and that is to refine radioactives into nuclear material. They could have bought control rods for a reactor from the Ruskies, Canadians, Germans, Japanese, but they chose the French. I wonder why? But lets not leave anyone out. The Germans were also in on it and they were kissy face with the French. Both were getting undervalued oil and the UN leadership was getting a cut under the table. The former fearless bash Busher in charge just retired this month as a multi-millionaire. Another reason to bail out of the UN. Personally I could give a shit about polls and analysis of this and that because POL is the first three letters of politics and ANAL is the first four of analysis.

Chan has but one task and that is to knock down disease. She has been on her one month honeymoon and already every country on the periphery of China is reporting bird bug without so much as a noise out of her except in the general sense. I would get those preparations for bird flu in order myself.

Revere is right though, WHO is charged with the fixing and if the fixing is political we are doomed when whatever it is comes.

This reality, that WHO is a toothless agency, but for its ability to speak publicly, is the world's tragedy.

The WHO is incapable of releasing the thousands of sequences collected in the search for understanding about H5N1 which are held at GenBank but are not available.

Ho Hum. WHO is not a regulatory agency. WHO is incapable of effectively lobbying to free the sequences. Ho Hum.

This week, Japan announces it has H5N1 and it's just like Qinghai. The sequences are not released. WHO says nothing, does nothing. WHO is not a regulatory agency. Ho Hum.

In the last few weeks, South Korea announces it has persistent and present H5N1, and, let's guess, it's just like Qinghai. The sequences are not released. WHO says nothing, and does nothing. WHO is not a regulatory agency. Ho Hum.

Dick Thompson goes on BBC and says, "Duh, I don't know" to the question of when a pandemic may break out. Very useful.
Ho Hum. WHO is not a thinking agency, never mind not being a regulatory agency. Is this incompetency? Or is it another opportunity to say, "They made some mistakes in the past, and let's move on". You know that anyone can say that at any time about anything. "He shot the president. He madea a mistake. He's not going to do it again." Same, no?

If you think that Dick Thompson's statements are of no serious impact, which is what I sense and surmise, you're just wrong. The consequence is that people all over the first world, who have the resources to do something about this, continue on, doing little at best, and nothing for the most part. They think, as normal people do, that the 20 year timeline is the more probable. All humans interpret reality in a way that favors their best interests. None want the pandemic. So, when Dick says, "Duh, don't know; maybe 20 years", the response from the public is "Tune Out. Turn Off. Drop Out." (hat tip to Tim).

I'm not venturing a statement that WHO is not doing its job. I can write your rebuttal; so I don't need to hear "WHO's not a regulatory agency."

My view is as to this pandemic, and frankly, while other diseases are important, (100% CFR in Egypt recently is a heads up when it's tied to N294S (a potential show stopper to the one backbone antiviral) and this little thing called flu), they don't hold a candle to what hypervirulent flu would and IMO will do to civilization. WHO's priorities, like the US president's in his State of the Union are set by its member states. It's just an intergovernmental agency.

Tragically, as we saw with the sequences out of Indonesia, WHO is the mother behind whose skirts, ignorant and unwilling nation-states can hide their sequences. WHO is just an intergovernmental agency; it's not a regulatory agency. It is undermining whatever else would emerge, and that can't be much worse than WHO. It guts creative solutions. Remember WHO's fabulous support for the investigation of Niman's recombination? NO? Good memory.

Remember Hans Stohr's squeeky car story? And what did Dick Thompson say about that? (It's rhetorical; don't bother answering.) And there are dozens and dozens of WHO's "intergovernmental" statements which have effectively slashed the legs out from under those who saw and who see the evolutionary trend. This year, so far is much worse (more death, more clusters, more widespread) than last.

And this is the part that stuns me as I hear the language of apologists...this was all known and conjectured by smart people who understood virology, Lvov for example.

You can do the world a favor by posting who said what over the past 2 years. Those who should be shunned will stand out like government employees in retraining classes.

IMO, take the gloves off. This virus took the gloves off. Why in heaven's name are we doing a Margaret Chan like argument here over SARS and who works harder? Enough.

(Ah, but that's not how it works, and the failure to believe that CFR would stay spectacular, that there are no ancillary low-virulence cases, that the virus would and now will continue to evolve by "duh I don't know" and will meet its obvious outcome (only obvious to those who choose to accept dialectic as reality) and the consequences will be ghastly and stunning, all those are grounds for retraining, or, as Revere states, "You try to do better and you hope others will help you to be better.")

As the question was insistenly asked;

from wikipedia: "Diplomatic immunity is a form of legal immunity and a policy held between governments, which ensures that diplomats are given safe passage and are considered not susceptible to lawsuit or prosecution under the host country's laws (although they can be expelled). ... Diplomatic immunity as an institution developed to allow for the maintenance of government relations, including during periods of difficulties and even armed conflict. When receiving diplomats - formally, representatives of the sovereign (head of state) - the receiving head of state grants certain privileges and immunities to ensure that they may effectively carry out their duties, on the understanding that these will be provided on a reciprocal basis."
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Diplomatic immunity is accorded to *individuals.* The home country can waive that immunity (the host country can only request it be waived.) The individuals are still subject to their own country's laws, and can be prosecuted under those laws for a crime he or she commits in the host country.

the conditions for US diplomats here:

http://www.state.gov/m/ds/immunities/c9127.htm

- for 'diplomatic staff in International Orgs. or missions' they cannot be arrested (they are expelled to the home country), cannot be detained (they are held in 'informal' house arrest), cannot be prosecuted (the respective Gvmts. will work out a deal, or not) their residence cannot be entered or searched (so this is hum never done) - and the same applies to family members.

In an organisations such as WHO, only a very few people would have diplomatic status. Their diplomatic status has absolutely nothing to do with the Organisation's actions (or inaction), although it is possible to imagine situations where it the two would interact.

Ana: Thanks. Useful explanation.

Apart from Dr. Chan's activities discussed so far, what is the general opinion of her committment to transparency? In particular does she believe that the general public should be afforded access to information or does she believe it is more important to avoid 'panic' and confusion from agency pronouncements that are not well disciplined.

I ask because at least to me it seems that WHO has limited its situation updates and other discussions of on-going events since the announcement of her selection in what could certainly be percieved as good message discipline. Unfortunately, while good message discipline is useful and effective in campaigns to persuade, they are less useful in campaigns to discover and communicate the truth.

Clarity and avoiding a multiplicity of conflicting statements is one thing, controlling the message to 'handle' the public - based on an assumption that the public will panic if given unvarnished truth - is quite another.

I don't yet have a good sense for which direction Chan would like to go - towards greater access to information or towards greater centralized control of the message.

ITW: She is on record as a strong proponent of transparency but that is to be expected. I haven't noticed a change since she started but I haven't been busy comparing before and after. Was there something in particular that struck you?

In general my attitude toward her is the same as it is to the science: I want to wait for the data.