|Now, I've always said that the WHO, like the other parts of the UN, is effective only in so far as its 'masters', ie the member states that make up the World Health Assembly, are willing to support it. For example, if money (and/or the control over money) is a measure of power, then a look at how the WHO's budget is put together becomes rather instructive. But, I'm getting ahead of myself. First, a caveat: as always, what I write is based on limited understanding, by following my intuition supplemented by the power of google. If there are core dysfunctions, those who hold high office at national and international levels are hardly likely to give us the straight-forward answers that we all seek. Hence, please take my musings with a good pinch of salt. ;-)
OK, as I said, several unrelated remarks triggered my curiosity and a sense of disquiet. Let me give you the big one first. For those who want a more comprehensive and chronological account of the session, I'd ask that you be patient and wait for the next diary, cos here I'm telling the story backwards. You'll see why in a minute.
David Heymann was on the panel for pandemic and emerging diseases (check out this page and scroll down for details). The moderator, Geoff Watts from the BBC, did a marvelous job leading the discussion given the short time, the no of panelists (6), and the need to bring the audience in to the discussion. Anyway, the last question that he posed to the panel, was how confident are they about all that's been done on the issue, are they very confident? Or are they filled with trepidation?
Most of the speakers expressed a mixed bag, of somewhat guarded confidence in certain specific areas, and concerns about other aspects or the sheer scale of the problem. David Nabarro expressed both confidence and trepidation, reiterating that the most important thing is never to be complacent, cos "that will be the beginning of the end". Ambassador John Lange, former US Special Representative on Avian and Pandemic Influenza, was more forthright given that he is no longer in office. "Am I confident? No. Do I feel the world is prepared? No." He referred to a recent report from the House Committee on Homeland Security, Getting Beyond Getting Ready for Pandemic Influenza, and said in essence we should BE ready already, but we are not. Olga Jonas from the World Bank said she shared Lange's view and was particularly concerned about developing countries being far less prepared.
Then David Heymann spoke, and said he was VERY confident, very optimistic, and here's why. He said that during SARS, the world worked together, countries shared information with each other. WHO gave out evidence-based recommendations, aka travel advisory warnings against certain cities, that would have negative consequences for the countries concerned, and yet the countries accepted the recommendations. Therefore he was very optimistic that countries can and will work together.
I don't know how others interpreted those remarks, but I'll tell you they threw me into a state of confusion. Cos it seemed to me he was answering a different question than I thought the moderator was asking. Did he misunderstand the question? Hardly likely, given that several people had already responded. Or was I somehow mistaken? I needed to find out.
So after the session, I posed the question to David Heymann again, in various forms, to say, are you confident about the state of preparedness of the world? Like if we have a severe 1918-like pandemic tomorrow, are we going to have a better outcome than say, 2 years ago? Are countries more prepared? Is he confident that countries are prepared? Anyhow, after a bit of to and fro, his response to whether countries are better prepared (or whether we will have a better outcome) was "I have no idea." He also said if a pandemic breaks out now, countries know what to do. They already know about closing gatherings, social distancing etc. I was rather shocked to hear him repeat the "I have no idea." at least one more time, such that I was left somewhat speechless. Perhaps it was just as well, cos I left soon after, and sleeping on a problem is often a good thing to do.
Anyhow, I remembered that earlier in the session he talked about the virus sharing situation. Again a remark stood out, not least because he repeated it a couple of times. He said the WHO has a new framework, the International Health Regulations or IHR(2005) which are legally binding agreements with the status of international law. But with the virus sharing negotiations, countries have chosen to 'go below the IHR', ie use a lower level resolution for the WHO to work on the problem. He repeated this again to say, the IHR is not being used. Countries are using a lower resolution.
Not quite understanding what he meant, I did a bit of poking around, and found this page with various WHO documents. Scroll down the page and you will come across a couple of documents on Pandemic influenza preparedness: sharing of influenza viruses and access to vaccines and other benefits. Here's an excerpt from appendix, describing the advisory group being set up to help resolve these issues. (Emphasis mine)
Background and mandate of Advisory Group
The Interim Statement adopted by WHO Member States attending the 20-23 November 2007 Intergovernmental Meeting on Pandemic Influenza Preparedness urged action to develop fair, transparent, and equitable international mechanisms on virus sharing and benefit sharing. Member States called on the Director-General to establish an Advisory Mechanism to monitor, provide guidance to strengthen the functioning of the trust-based system needed to protect public health and undertake necessary assessment of that system. To carry this out, Member States specified that an Advisory Group will be appointed by the Director-General in consultation with Member States, based on equitable representation of the WHO regions and of affected countries.
The trust-based system is now referred to as the "Pandemic Influenza Preparedness Framework for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits" (hereinafter "the Framework"). The scope of the Advisory Group is to monitor, assess and report on the system for sharing H5N1 influenza viruses and other influenza viruses with human pandemic potential as well as access to vaccines and other benefits of the Framework. The institutional components of the Framework to be monitored by the Advisory Group are National Influenza Centres, Other authorized laboratories, WHO Collaborating Centres, H5 Reference Laboratories, and essential regulatory laboratories, as defined in Section  of the Framework. [The pharmaceutical industry is not included although they can be consulted (but not monitored) by the Advisory Group.]
I don't know enough about this kind of language to be certain, but it seems to me that a 'trust-based system' refers to something that is non-binding, and certainly not at the level of 'international law' or treaty that the IHR belongs to. If that is what David Heymann was referring to, I'm somewhat disturbed that after so many years of work, with the IHR supposedly resting at the core of the global public health security mechanism, the very first time that conflicts of interest arise, member states are choosing to NOT work within the IHR, but choose to negotiate a complex but non-binding set of agreements outside of the IHR. I have no idea how well this is going to play out, whether it will successfully resolve the virus sharing problem, but if that is what the member states are asking the WHO Secretariat to do, it looks to be both time- and resource-consuming as well as probably ultimately unlikely to succeed. Of course, we don't know what Heymann's opinion is/was on this, since he did not (or could not) say, but I suppose he and his colleagues don't really have a choice, other than to follow the directives from the member states.
Finally, something else that another speaker had said earlier came to mind. In referring to the need to support the WHO, someone said that of course it's very difficult since only 30% of their programme budgets are discretionary, or something to that effect. Again, I looked to google, and found this page of documents from the WHA.
Looking through various documents under Medium Term Strategic Plans 2008-2013 and Draft Programme Budget 2010-11, I learned that the WHO's work is funded broadly via one of 2 routes: assessed contributions, which are the standard contributions that member states make, and voluntary contributions, which come from a variety of sources and partnerships. Over the years, there's been an increasing trend for partnerships and other collaborations, and over time, the voluntary contributions make up an increasingly large proportion of programme funding, as shown in the following chart from the WHO strategic plans document: (click to enlarge)
The problem is voluntary contributions are often earmarked for specific purposes, such that there is less flexibility in how the WHO can spend the money. In essence, if no one puts up the money for a particular area of work, that area will have to be funded from the very limited assessed contributions pool in competition with every other programme with the same predicament, ie items that are not explicitly funded by donors or partnerships are at risk of being severely under-resourced.
Concern has been expressed in various places that "the substantial increase in Voluntary Contributions might not align with the programme priorities" (source). Indeed, the Medium Term Strategic Plan itself says "it is therefore essential for the Organization's credibility and integrity that a significant portion of its budget should be financed through assessed contributions."
It would seem that this aspiration has been difficult to achieve. The chart above ended in 2007, with 71% of the budget being funded via voluntary contributions, but this proportion is expected to rise to an astonishing 82.7% in the 2010-11 budget (see chart below, red arrows)
The only saving grace is there IS one earmark for avian flu, and that is $30M from the WHO/FAO/OIE agreement on the management of avian influenza and other emerging diseases, for the 2-years from 2010-11. Maybe that's why David Heymann, in response to the discussion on the approach to pandemic flu, reiterated that the WHO "now takes a more comprehensive approach", and is focused on trying to "find disease in animals before they go to humans".
But THAT, of course, is not quite the same as preparing to mitigate the effects of an influenza pandemic AFTER the virus has successfully jumped species...