WHO, swine flu in the Ukraine and bin Laden's beard

We were asked repeatedly offline and in the comments for our views on what was or was not going on in the Ukraine, but we steadfastly declined to post on it. We didn't know any more than you can find out from news sources, so we had nothing to add in the way of hard information, We did know there was a WHO team on the ground and we thought it best to wait to find out more. We still don't know much, except that news reports are suggesting that the health care system in the Ukraine is a shambles and its likely the chaos and panic were self-inflicted more than virally inflicted. Mike Coston over at Avian Flu Diary has a great run down and we agree with the way he approached it -- gingerly, cautiously but with the right amount of anxiety that something could be happening but it was best to wait for information before hitting the alarm button (I didn't say panic button because it's never appropriate to hit the panic button).

Meanwhile, multiple stories out of the Ukraine were detailing disorganization, incompetence, politicization of the outbreak during a presidential campaign and much else. Few citizens believed what their leaders or government were saying, which is probably just as well because the messages were often contradictory and confused. The most recent version of this is from the New York Times:

Early findings are that serious cases mounted because the sick avoided hospitalization until their illness was dangerously advanced, stockpiles of Tamiflu were locked in centralized locations and the supply of ventilators fell short, said David Mercer, of the World Health Organization’s European regional office.

“It’s not like this caught us by surprise; we’ve known for months that this was coming,” said Dr. Mercer, who heads the office’s communicable disease unit. “We’ve been working very hard on plans, but sometimes the battle plan doesn’t survive the first contact with the enemy. We’ve had to change a lot of things on the fly.” (Ellen Barry, New York Times)

Here's an earlier report from Ukraine's English language Kyiv Post:

Public officials have known for many months that it was a matter of when, not if, the swine flu would arrive in Ukraine. Nevertheless, they provided little advance notice and took few precautionary measures. The Cabinet of Ministers in April 2009 provided the Health Ministry with only $6 million (Hr 50 million) to prepare for a swine flu epidemic. But not even that modest amount was well-spent, it appears.

“The money was allocated for . . . drugs, laboratories, artificial respirators, test systems . . . everything necessary to get the patient out of the critical condition,” Prime Minister Yulia Tymoshenko told lawmakers on Nov. 3. A day earlier, the General Prosecutor’s Office opened a criminal investigation into how the funds were allegedly misallocated.

Time and money— half a year and Hr 50 million— were not used wisely to prepare the nation for the approaching epidemics.

“There are no test systems or antibiotics. Hospitals are not equipped with artificial respirators. All the drugs and equipment are either in transit or storage,” Tetyana Bakhteeva, chairwoman of parliament’s health committee, said on Nov. 3.

Victor Ovrachuk, deputy head of the Ternopil Oblast administration health directorate, agreed.

“We have not received laboratories, artificial respirators or antibiotics. We have received a two-day supply of the antiviral medication Tamiflu. That’s about it,” Ovrachuk told the Kyiv Post on Nov. 4.

It was the same story in Luhansk. “We paid for test systems from our regular budget. We did not get the equipment we needed the most,” Anatoly Dokashenko, Luhansk’s chief sanitary doctor said.

He criticized the centralized state purchases, insisting regional government is more aware of their needs. “We know locally what exactly we lack and what exactly we need,” Dokashenko added

Piet Spijkers of Dutch Humanitarian Aid described the situation at Lviv Oblast hospitals his organization supports as “appalling.” He said on Nov. 4 that there is a lack of basic medical supplies, barely any flu tests, vaccines or antiviral drugs, such as Tamiflu. (Kyiv Post, "Pandemic politics")

WHO's regional office in Europe did send a team there and the above notwithstanding, here is what it reported on November 12, 2009:

Health facilities in Ukraine well prepared for pandemic (H1N1) 2009 influenza

12 November 2009

On Wednesday, 11 November, the last WHO regional investigation team returned to Kyiv. While the teams have yet to finish drawing conclusions, they found health facilities in Ukraine well prepared and highly motivated to deal with the influx of cases.

In separate meetings with the Prime Minister and the President of Ukraine on Monday, 9 November (also attended by the ministers of Foreign Affairs and Health), the WHO mission thanked the Government for its openness and providing unrestricted access to facilities and data. The discussion focused on further action needed to combat the disease, particularly vaccinating the main risk groups in the population. WHO once more offered its full support in all necessary activities.

On 11 November, the Ministry of Health arranged and led a teleconference in Kyiv, connecting 486 hospitals and nearly 10 000 doctors in all 27 regions of Ukraine to facilitate sharing of clinical experience and lessons learned in fighting the pandemic (H1N1) 2009 virus. Clinicians in the worst affected areas had detailed discussions on what therapies they had used and how these could be adapted for the future. The participants discussed a wide range of issues and developments, including primary, obstetrical and intensive care and the essential supplies and equipment that were currently available and being mobilized. (Statement by WHO's Regional Office for Europe)

So while we waited for WHO's team to report about reports that were at the least, worrying, they were concocting crap like this. Anything in this statement that isn't completely vacuous is just plain bullshit. WHO is an intergovernmental organization that is subservient to its member nations. We've explained that often here, often in sympathetic terms. But there comes a time when the niceties of diplospeak conflict with telling the truth. When that time comes, it's better to shut up rather than mouth utter tripe.

Sometimes it's the opposite of what our mother's taught us about polite discourse: if you can't say something bad about someone, you shouldn't say anything at all. Because once you start telling the world what a nice beard Osama bin Laden has, they will stop listening to you, no matter what else you say.


More like this

The whole Ukraine situation has been a tale of utter incompetence by the WHO. Despite doctors in Ukraine having no idea what they were dealing with after the first few cases started showing up in early October, the earliest WHO announcement, issued in early November, was that "there was no evidence" that there had been any outbreak of swine flu in Ukraine (despite swine flu watchers knowing with near certainty that that was exactly what it was). They then took their sweet time about assembling a team to visit Ukraine, finally days later sent them on their way, and ultimately changed their initial assessment to declare that it was, indeed, swine flu. And, then, some amount of time later, issued guidance that Tamiflu (i.e., antiviral drugs) should be administered as soon as possible. People's loved ones (numbering in the many hundreds) were dying horrible deaths involving total disintegration of the lungs while those incompetent bureaucrats were asleep at the wheel.

Yes. Exactly. I always wish that authorities, whether we're talking about WHO or the local county government, would find a better balance between the "nothing to see here" quell-the-panic move and the "holy crap, we're all going to die" move.

When agencies try to tamp down panic by offering obvious bullshit, all they do in the long run is make the public question everything they say, which in turn only exacerbates the panic. Personally, I feel more secure when I feel like I'm getting a truthful representation of a bad situation from the agencies trying to track it, but that hasn't been my experience (generally or in this pandemic), and now I don't trust any of them as far as I can throw them.

If agencies really want to manage fear, they need to be both calm and really honest about the situation, both in terms of what's known and what remains to be learned. There will always be a subpopulation that insists that the authorities are lying about everything, and there will always be rumors and fears, but most people just want to feel that they have the best information available.

While there have been confirmed cases of the swine flu in Ukraine, what is really going on is an unknown virus doing things to the lungs the swine flu hasn't even thought about doing. It is this mysterious virus that has us all concerned, and the effects of which have been confirmed by numerous articles coming out of the Ukraine, like here: http://www.express.co.uk/posts/view/140492/Million-hit-by-plague-worse-…-

not to mention the fact that the WHO never bothered to close their borders. Something is going on over there and the MSM has yet to utter a peep, never mind we know they have the resources to tell us what is going on on-site.

jrl: That news report is also bullshit. None of it makes any sense. And WHO cannot close borders. Only a sovereign nation can close its own borders. That's the way the international system works because there is no power above nation states. See the link in the post if you want to understand the WHO system. If you do.

I live in the Ukraine and I write this post from Kiev.

Well, the situation here is 100% FUBAR. During the first days of the epidemics there was a shortage of face masks (even now it's hard to buy them). All anti-fever medication was also out of stock in the matter of hours.

NOBODY here had been vaccinated by the time the epidemics has started. Even health care professionals.

Government was also completely unprepared and incompetent. For example, the vice-minister of health-care publicly told that: "We won't use Terraflu (sic!) because it's just a drug that boosts immunity, we'll use oseltamivir", - when asked about Tamiflu supply.

But wait! There's more! A representative of Ukrainian parliament publicly told that he was sick with, wait for it, _bubonic_ _plague_ and not flu.

And there's more! The Ukrainian president has vetoed emergency funds appropriation for swing flu counter-measures.

Absolutely total f&^#*&$^#*&^ing mess.

By Alex Besogonov (not verified) on 16 Nov 2009 #permalink

So just to be clear Alex you think it could have been handled better?

Early findings are that serious cases mounted because the sick avoided hospitalization until their illness was dangerously advanced,

Sounds like the citizens are afraid of their own hospitals.

jrl wrote, "While there have been confirmed cases of the swine flu in Ukraine, what is really going on is an unknown virus doing things to the lungs the swine flu hasn't even thought about doing. It is this mysterious virus that has us all concerned, and the effects of which have been confirmed by numerous articles coming out of the Ukraine...."

No. There is no mystery virus or bioweapon or some other comic book fantasy going on in Ukraine. The lung hemorrhaging is a signature aspect of swine flu. Here, for example, is a late September article about a 19 year old from Massachusetts who had just been dropped off by his parents to start his first semester of college in Ohio: http://www.boston.com/news/local/massachusetts/articles/2009/09/28/hing… .

So the WHO and even casual swine flu watchers knew what was going on in Ukraine and the WHO still allowed this to happen: http://www.nytimes.com/2009/11/14/world/europe/14flu.html?_r=1

"So just to be clear Alex you think it could have been handled better?"


By Alex Besogonov (not verified) on 16 Nov 2009 #permalink

Re: WHO statement headed "Health facilities in Ukraine well prepared for pandemic (H1N1) 2009 influenza"

Like you, Revere, I am also often sympathetic about the need for some degree of WHO-speak.

But it is inconceivable that this particular statement was written by anyone at WHO who is familiar with the WHO Outbreak Communication Guidelines, which argue for transparency and candor, in the service of building trust and confidence in officials in order that they may more effectively lead their citizens through an outbreak.

While it may be politically expedient, the language in the Ukraine statement has little potential for increasing Ukrainians confidence in their government, and significant potential for reducing public trust and confidence in WHO.

If WHO can issue such a positive statement about Ukraine's pandemic preparedness, what are attentive publics supposed to believe when WHO issues similarly positive statements about such issues as vaccine safety and efficacy?

The first of the five WHO outbreak communication guidelines states:

"The overriding goal for outbreak communication
is to communicate with the public in ways that
build, maintain or restore trust. This is true
across cultures, political systems and level of
country development."

The WHO Outbreak Communication Guidelines discuss the limits of transparency, but they do not say that there is ever a time to issue patently false statements. At most, if necessary to maintain a working relationship with a Member State, it may be justifiable to remain publicly silent while being fully transparent with the Member State in private, rather than making a manifestly unsupportable claim.

And of course there are also times -- in international health emergencies like SARS, for instance -- when it is necessary for WHO to go public even when a Member State is not reporting a known outbreak.

WHO is often publicly silent when Member States mis-report in glowing terms what WHO officials have actually said to them, or said about them. This is apparent when published quotes from WHO officials do not match the published paraphrases of those quotes by Member State officials.

WHO has often been publicly silent during this pandemic, when Member States report that they are performing various interventions "in accord with WHO [technical] guidelines," even when the WHO guidelines suggest the opposite interventions. (Certain containment measures come to mind.)

Other times, WHO has adequately used WHO-speak to publicly signal their opinion about a Member State's practices, as in this statement about China's initial containment policies:

"If the flu starts spreading rapidly, the Chinese government may need to rethink its quarantine policy." Reuters, June 11 2009

Strategic silence is, at times, completely justifiable, as in the limits of transparency described in the outbreak communication guidelines. Other times, it is a somewhat justified sin of omission. But blatant misrepresentation should have no place in outbreak communication.

Submitted by Jody Lanard, M.D., Manila, the Philippines

Ukraine also happens to have the highest prevalence of HIV/AIDS in Eastern Europe. Yes, worse even than Russia. A UNAIDS report in 2008 says the HIV rate has been doubling every year since 2001, mainly through IV drug use and the sex industry. Which means the same age groups (ie young adults) who are most at risk from H1N1 are also the same people who probably have the highest prevalence of HIV, MUCH higher even than the national average. With their infrastructure (or lack thereof) I suspect for every known case of HIV, there are many undiagnosed. And the vast majority of HIV-positive people are probably not on anti-retrovirals.

Parallel to that, Ukraine is also listed as 1 of 18 countries with high prevalence of TB, in E Europe and Central Asia. Again, a high proportion is probably untreated or inadequately treated.

more here http://www.newfluwiki2.com/showComment.do?commentId=147672

So, if you have a lot of HIV and TB, very little tamiflu, delayed treatment, poor health infrastructure, possibly widespread self-medication with potentially harmful meds like aspirin, then you've got a recipe for a whole lot of grieve, and the kind of alarming and rapid deaths that are reported in the stories.

I don't know if that's enough to account for the numbers, since we have little certainty about the numbers. I'd just say, many parts of Eastern Europe, is a train wreck waiting to happen. Ukraine happens to get it earlier than some others, maybe. Maybe other countries in the former Soviet union that are affected later will learn from their mistakes. Or maybe not.