I’m mildly obsessed with the flu. I’ll admit it. I blame Alfred Crosby and his chilling book, America’s Forgotten Pandemic, about the Spanish flu and its erasure from historical memory. (Katherine Anne Porter’s infinitely sad novella, Pale Horse, Pale Rider, is also partly responsible.)
So, naturally, a recent article by Harvey Fineberg in the New England Journal of Medicine caught my eye. The current president of the Institute of Medicine and the co-author of The Swine Flu Affair, Fineberg served as the chairman of a committee formed under the auspices of the World Health Organization (WHO) to review the international community’s response to the H1N1 pandemic of 2009. Fineberg’s post mortem (as it were) raises serious concerns about the existing governance structure for dealing with global outbreaks:
First, the WHO is simultaneously the moral voice for health in the world and the servant of its member states, which authorize the overall program and budget. National interests may conflict with a mandate to equitably protect the health of every person on the planet. Second, the budget of the WHO is incommensurate with the scope of its responsibilities. Only approximately one quarter of the budget comes from member-state assessments, and the rest depends on specific project support from countries and foundations. These budget realities and the personnel-management requirements inherent in being a United Nations agency constrain flexibility.
Third, the WHO is better designed to respond to focal, short-term emergencies, such as investigating an outbreak of hemorrhagic fever in sub-Saharan Africa, or to manage a multiyear, steady-state disease-control program than to mount and sustain the kind of intensive, global response that is required to deal with a rapidly unfolding pandemic. Finally, the regional WHO offices are autonomous, with member states of the region responsible for the election of the regional director, budget, and program. Although this system allows for regional variation to suit local conditions, the arrangement limits the ability of the WHO to direct a globally coherent and coordinated response during a global health emergency.
Even if you don’t stay up late worrying about zoonoses, read the article. Now is the time to get the international governance regime in order. We can’t afford to wait until the next flu pandemic strikes.