Tuesday, March 4, 2008
Blog on hold
I have accepted an interim position as the news team leader at the World Health Organization. During this period, I will not be posting to this blog. Thank you for visiting the site and I will be back in a few months.
Tuesday, January 22, 2008
How long can WHO say "We don't know"?
Once again the question arises about whether H5N1 will ever ignite a human influenza pandemic, which was outlined this time in a story in the NY Times today. This question will persist and may become more urgent the longer H5N1 continues to circulate and public health resources are diverted to prepare for a pandemic. Now, as in the past, the discussion becomes a story of dueling expert opinion lobbed back and forth in the press and blogs. This is not helpful either as guidance to countries or members of the public who deserve the best information available to make their own informed decisions. But as a former WHO communicator, unanswered allegations of crying wolf could undermine the public’s trust in WHO, trust which has been hard earned and will be needed in a pandemic.
When we first identified the current threat, WHO wisely stated that there were many questions that could not be answered about a possible human H5N1 pandemic. “I don’t know,” was often used and I believed that this candid admission was honest, wise and would build trust because it reflected the state of our knowledge. But here we are, about three years since WHO warned a “pandemic may be imminent” and many if not most of the questions about the likelihood of an H5N1 pandemic remain unanswered.
I proposed while at WHO, and do again here, that the organization hold an open meeting of experts to elicit individual judgments (not a consensus) on a few questions including:
• How likely is it that H5N1 will cause a human influenza pandemic and what informs that judgment?
• What are the information components needed to better answer this question?
• What would we need to know about pandemics and about H5N1 to lower our concern?
• How could we get that information?
It has been said that “(e)xpertise counts for a lot, but only by way of informing subjective judgment. To assign a number to the likelihood that something will occur is to expose one’s judgment for comparison with that of others. This leads to explicitness about everyone’s reasons. If two people assign different numbers, the question becomes, why? That starts them digging into the detail of their own—and each other’s—reasoning.”
An expert panel also once said that such a meeting should include those outside the “influenza fraternity” and I believe that advice is still wise. This very small group has seemed to me to be able to write a meeting’s conclusions as the meeting is being planned.
Maybe the best answer coming out of such a meeting would still be “I don’t know.” But WHO should strive, and be seen to be striving to ensure the public has the best information possible. An open meeting would allow WHO and others to share this dilemma with the public. In the process, such a meeting might set a useful public health research agenda. From a WHO communicator’s point of view, it would undermine the assertion that WHO has "raised alarms to raise funds" by demonstrating that WHO regularly reassesses its assumptions and openly seeks more information. And perhaps the most important benefit of such a meeting would be to further educate the public so that the best decisions can be made about how to allocate the limited amount of resources available to public health.
[The idea for the proposed meeting and agenda questions and, the long quote above, come out of my reading of the “The Swine Flu Affair: Decision-Making on a Slippery Disease” by Richard E. Neustadt and Harvey V Fineberg, DHEW, 1978.]
When we first identified the current threat, WHO wisely stated that there were many questions that could not be answered about a possible human H5N1 pandemic. “I don’t know,” was often used and I believed that this candid admission was honest, wise and would build trust because it reflected the state of our knowledge. But here we are, about three years since WHO warned a “pandemic may be imminent” and many if not most of the questions about the likelihood of an H5N1 pandemic remain unanswered.
I proposed while at WHO, and do again here, that the organization hold an open meeting of experts to elicit individual judgments (not a consensus) on a few questions including:
• How likely is it that H5N1 will cause a human influenza pandemic and what informs that judgment?
• What are the information components needed to better answer this question?
• What would we need to know about pandemics and about H5N1 to lower our concern?
• How could we get that information?
It has been said that “(e)xpertise counts for a lot, but only by way of informing subjective judgment. To assign a number to the likelihood that something will occur is to expose one’s judgment for comparison with that of others. This leads to explicitness about everyone’s reasons. If two people assign different numbers, the question becomes, why? That starts them digging into the detail of their own—and each other’s—reasoning.”
An expert panel also once said that such a meeting should include those outside the “influenza fraternity” and I believe that advice is still wise. This very small group has seemed to me to be able to write a meeting’s conclusions as the meeting is being planned.
Maybe the best answer coming out of such a meeting would still be “I don’t know.” But WHO should strive, and be seen to be striving to ensure the public has the best information possible. An open meeting would allow WHO and others to share this dilemma with the public. In the process, such a meeting might set a useful public health research agenda. From a WHO communicator’s point of view, it would undermine the assertion that WHO has "raised alarms to raise funds" by demonstrating that WHO regularly reassesses its assumptions and openly seeks more information. And perhaps the most important benefit of such a meeting would be to further educate the public so that the best decisions can be made about how to allocate the limited amount of resources available to public health.
[The idea for the proposed meeting and agenda questions and, the long quote above, come out of my reading of the “The Swine Flu Affair: Decision-Making on a Slippery Disease” by Richard E. Neustadt and Harvey V Fineberg, DHEW, 1978.]
Thursday, January 10, 2008
China’s h2h
It is good to see China acknowledging the possibility of human-to-human transmission of bird flu. Today’s announcement was made by the ministry of health in a Webcast briefing.
The outbreak in question occurred last month in Nanjing and involved a 24-year-old man and the man’s father, who developed fever a day after his son died. Transmission seems to have stopped with the father who survived.
I have long thought that China has tried hard to do better outbreak communication in the wake of their disastrous performance during SARS. Slowly, as with any large bureaucracy, those changes are seeping into practices of the vast Ministry of Health.
While the announcement is a welcome move, I would have encouraged China to make this announcement much earlier. The son died on December 2, 2007. So today’s acknowledgment comes a full month after the fact.
Very likely, the Chinese wanted to wait until they knew that the outbreak was over, that no other cases were found, and that the molecular analysis was completed (as it appears to be) showing no worrying mutations*. In other words, that there was no continuing risk. But in an urgent public health setting, which this could have been if more people were infected, rapid disclosure of information would have been essential.
So why the delay? My experience is that it is a typical response. All technical agencies, not just in China's MOH alone, have a culture of precision which abhors uncertainty. In a situation like this outbreak, the technical people might have vigorously argue for delay until more could be known with confidence. And those responsible for making communication decisions often hide behind this technical justification since they are reluctant to deliver bad news at all. As with most outbreak communication practices, the easy way out can cause more problems.
There are ways of talking about developing and even unreliable information. In fact, early in any outbreak, poor information is about all there is available. The public can usually live with uncertainty much better than with silence. As one of my bosses used to say: You don't wait until you know what set your home ablaze before you call the fire department. Moreover, providing information as develops demonstrates trust-building transparency and helps educate the public along the way.
So, today's announcement was a step toward rebuilding the world's trust in China. Those who made this decision should be congratulated. But this delayed reporting still leaves unanswered the question of when China would have announced if the situation was more worrisome. As the China is learning, once trust is lost, it is not easily restored.
[*Mutations seem to have become a barometer of concern. Indeed, molecular analysis will help clarify the viruses potential. But wouldn't a better indicator be the epidemiology? One sick nurse, who had treated an H5N1 patient, may raise WHO's blood pressure long before sequencing is complete.]
The outbreak in question occurred last month in Nanjing and involved a 24-year-old man and the man’s father, who developed fever a day after his son died. Transmission seems to have stopped with the father who survived.
I have long thought that China has tried hard to do better outbreak communication in the wake of their disastrous performance during SARS. Slowly, as with any large bureaucracy, those changes are seeping into practices of the vast Ministry of Health.
While the announcement is a welcome move, I would have encouraged China to make this announcement much earlier. The son died on December 2, 2007. So today’s acknowledgment comes a full month after the fact.
Very likely, the Chinese wanted to wait until they knew that the outbreak was over, that no other cases were found, and that the molecular analysis was completed (as it appears to be) showing no worrying mutations*. In other words, that there was no continuing risk. But in an urgent public health setting, which this could have been if more people were infected, rapid disclosure of information would have been essential.
So why the delay? My experience is that it is a typical response. All technical agencies, not just in China's MOH alone, have a culture of precision which abhors uncertainty. In a situation like this outbreak, the technical people might have vigorously argue for delay until more could be known with confidence. And those responsible for making communication decisions often hide behind this technical justification since they are reluctant to deliver bad news at all. As with most outbreak communication practices, the easy way out can cause more problems.
There are ways of talking about developing and even unreliable information. In fact, early in any outbreak, poor information is about all there is available. The public can usually live with uncertainty much better than with silence. As one of my bosses used to say: You don't wait until you know what set your home ablaze before you call the fire department. Moreover, providing information as develops demonstrates trust-building transparency and helps educate the public along the way.
So, today's announcement was a step toward rebuilding the world's trust in China. Those who made this decision should be congratulated. But this delayed reporting still leaves unanswered the question of when China would have announced if the situation was more worrisome. As the China is learning, once trust is lost, it is not easily restored.
[*Mutations seem to have become a barometer of concern. Indeed, molecular analysis will help clarify the viruses potential. But wouldn't a better indicator be the epidemiology? One sick nurse, who had treated an H5N1 patient, may raise WHO's blood pressure long before sequencing is complete.]
Saturday, January 5, 2008
In a word: Containment
When the global surveillance system (very likely the media component) first identifies that a pandemic virus has finally emerged, it will likely set in motion an effort by the World Health Organization to contain it at the outbreak site. Containment of a pandemic virus is an untested public health intervention. WHO was forced to embrace the concept of containment when two computer modeling studies published in high profile, peer reviewed journals suggested that -- under the right circumstances -- it might be possible to extinguish the first outbreak of a pandemic virus locally and thus keep it from spreading globally.
WHO set about working out the details of how to do that, and right now it's Global Influenza Program is again revising the so-called "Containment Protocol." This latest iteration of the containment plan is scheduled for release in May. But developing each version of the protocol has been a struggle to marry the theoretical models with the likely reality. Few scientists now believe that containment is actually achievable.
Nevertheless, when a containment effort is launched, it will likely get the full Britney Spears treatment of "Live from the scene" 24-hour-a-day coverage. Intense media coverage, like the containment effort itself, is probably justified since the consequences of a pandemic virus escaping from a containment zone would have broad impact and could be extreme.
This coverage will certainly draw the attention of a new and largely uninformed audience. To date, most of those following the H5N1 story have been public health experts, the poultry industry, Helen Branswell readers, and a few survivalist types who have focused on other threats as H5N1 has, so far, refused to meet its pandemic potential. A containment effort will change that. Very possibly, the world's attention will be riveted on a distant land as WHO and others struggle in spacesuits to prevent what commentators may announce as the first step toward a global calamity.
And with the world watching, containment will likely fail. Almost no expert honestly believes a pandemic can be stopped under the likely outbreak conditions. Too many variables -- biological, cultural, political and logistical -- need to align themselves perfectly for the pandemic to be quenched. Thus, with millions of people rapt with news of containment, the first public health intervention will fail. And this is an enormous communication challenge.
Communication is a public health tool. Building, maintaining or restoring trust is always the first goal of outbreak communication. Trust is the currency of our work. Each communication, like each action, either earns or spends that trust.
In the early stages of a pandemic, little will be available help most people. But a pandemic is a marathon. So it is essential that trust in public health authorities is maintained throughout a pandemic. If their debut is seen as clumsy and inept, trust will be severely strained and that leaves the world more vulnerable to, not just health, but also the social, economic and political consequences of a pandemic.
I believe that the seed of containment's failure is in the word itself. It is a binary word. Something is contained or not. WHO and other institutions and experts have been trapped into using the word because it was associated with the first modeling papers published and the enthusiasm for the possibility generated at that time. They have continued to use the word because the sales pitch of success helps justify the extraordinary and even severe measures that would be asked of populations, governments and agencies during a containment effort.
In the months following publication of the initial papers, understanding of an actual containment process evolved and it became evident that a human influenza pandemic virus was very likely unstoppable. But that same evolution in planning revealed that a pandemic could be slowed, perhaps by weeks. And weeks would certainly provide more time for vaccine production (which has its own problems which I'll outline in a later posting). It also provides time to launch social distancing and other non-pharmaceutical public health interventions such as hand-washing campaigns, home care and the use of masks.
I believe that WHO and others should stop using the word now. What is needed is a word to replace "containment" -- something like delay-ment or restrain-ment. Something is needed that identifies a reasonable goal (to slow the spread of the virus), but does not instantly raise expectations. As I said, expectations are not high among the experts, but with the launch of a containment effort, there will be a new global audience that will be very worried and very hopeful. To me, maintaining the public's trust in health authorities throughout a pandemic is as important as restraining the spread of the virus at the start. An initial, high-profile failure of containment won't help build trust.
A good start could be made right now by renaming the upcoming version of WHO's Containment Protocol.
When the global surveillance system (very likely the media component) first identifies that a pandemic virus has finally emerged, it will likely set in motion an effort by the World Health Organization to contain it at the outbreak site. Containment of a pandemic virus is an untested public health intervention. WHO was forced to embrace the concept of containment when two computer modeling studies published in high profile, peer reviewed journals suggested that -- under the right circumstances -- it might be possible to extinguish the first outbreak of a pandemic virus locally and thus keep it from spreading globally.
WHO set about working out the details of how to do that, and right now it's Global Influenza Program is again revising the so-called "Containment Protocol." This latest iteration of the containment plan is scheduled for release in May. But developing each version of the protocol has been a struggle to marry the theoretical models with the likely reality. Few scientists now believe that containment is actually achievable.
Nevertheless, when a containment effort is launched, it will likely get the full Britney Spears treatment of "Live from the scene" 24-hour-a-day coverage. Intense media coverage, like the containment effort itself, is probably justified since the consequences of a pandemic virus escaping from a containment zone would have broad impact and could be extreme.
This coverage will certainly draw the attention of a new and largely uninformed audience. To date, most of those following the H5N1 story have been public health experts, the poultry industry, Helen Branswell readers, and a few survivalist types who have focused on other threats as H5N1 has, so far, refused to meet its pandemic potential. A containment effort will change that. Very possibly, the world's attention will be riveted on a distant land as WHO and others struggle in spacesuits to prevent what commentators may announce as the first step toward a global calamity.
And with the world watching, containment will likely fail. Almost no expert honestly believes a pandemic can be stopped under the likely outbreak conditions. Too many variables -- biological, cultural, political and logistical -- need to align themselves perfectly for the pandemic to be quenched. Thus, with millions of people rapt with news of containment, the first public health intervention will fail. And this is an enormous communication challenge.
Communication is a public health tool. Building, maintaining or restoring trust is always the first goal of outbreak communication. Trust is the currency of our work. Each communication, like each action, either earns or spends that trust.
In the early stages of a pandemic, little will be available help most people. But a pandemic is a marathon. So it is essential that trust in public health authorities is maintained throughout a pandemic. If their debut is seen as clumsy and inept, trust will be severely strained and that leaves the world more vulnerable to, not just health, but also the social, economic and political consequences of a pandemic.
I believe that the seed of containment's failure is in the word itself. It is a binary word. Something is contained or not. WHO and other institutions and experts have been trapped into using the word because it was associated with the first modeling papers published and the enthusiasm for the possibility generated at that time. They have continued to use the word because the sales pitch of success helps justify the extraordinary and even severe measures that would be asked of populations, governments and agencies during a containment effort.
In the months following publication of the initial papers, understanding of an actual containment process evolved and it became evident that a human influenza pandemic virus was very likely unstoppable. But that same evolution in planning revealed that a pandemic could be slowed, perhaps by weeks. And weeks would certainly provide more time for vaccine production (which has its own problems which I'll outline in a later posting). It also provides time to launch social distancing and other non-pharmaceutical public health interventions such as hand-washing campaigns, home care and the use of masks.
I believe that WHO and others should stop using the word now. What is needed is a word to replace "containment" -- something like delay-ment or restrain-ment. Something is needed that identifies a reasonable goal (to slow the spread of the virus), but does not instantly raise expectations. As I said, expectations are not high among the experts, but with the launch of a containment effort, there will be a new global audience that will be very worried and very hopeful. To me, maintaining the public's trust in health authorities throughout a pandemic is as important as restraining the spread of the virus at the start. An initial, high-profile failure of containment won't help build trust.
A good start could be made right now by renaming the upcoming version of WHO's Containment Protocol.
Thursday, December 27, 2007
Naming the next pandemic
When I helped name SARS (on a frenzied Saturday morning), one of our chief concerns at the World Health Organization was to create a name that would not stigmatize any group or nation. The Spanish flu and the Hong Kong flu are reminders of how important a name can be. Decades earlier, I worked in San Francisco when a new disease was detected and given the name Gay Related Immune Deficiency. This was inappropriate for lots of reasons, chiefly that it misled some people to believe that infection could be acquired with casual association with a gay person and that non-gays were not at risk. HIV and AIDS are much better identifiers. SARS showed us that a benign name doesn't eliminate stigma but it can reduce it.
At WHO, I was concerned for years about the name of the next pandemic. Still, after years of wrestling with the problem, the next pandemic is without a name or even a procedure for naming the outbreak. This important job is very likely to fall to a headline writer. Which means, the next pandemic could be called the Jakarta Flu or maybe the Portland Pandemic.
Any ideas?
(BTW, I didn't do so well with SARS. After creating the name, I did a quick search and found that "SARS" would not be a problem. But I didn't search "SAR" which was how Hong Kong, Special Administrative Region of China was called, and Hong Kong was hard hit by the disease.)
At WHO, I was concerned for years about the name of the next pandemic. Still, after years of wrestling with the problem, the next pandemic is without a name or even a procedure for naming the outbreak. This important job is very likely to fall to a headline writer. Which means, the next pandemic could be called the Jakarta Flu or maybe the Portland Pandemic.
Any ideas?
(BTW, I didn't do so well with SARS. After creating the name, I did a quick search and found that "SARS" would not be a problem. But I didn't search "SAR" which was how Hong Kong, Special Administrative Region of China was called, and Hong Kong was hard hit by the disease.)
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