Politics play big role in world health decisions

updated 12:27 p.m. ET May 3, 2009

GENEVA - At the U.N. agency spearheading the fight against swine flu, key decisions are based on more than just health issues — politics plays a big role, too.

With global powers like the United States and China all lobbying for their own national interests behind the scenes, measures such as travel bans, border closures, and raising alert levels can meet stiff political opposition. Some have even wondered if granting the World Health Organization beefed up powers to independently tackle health crises might help, giving it authority to make key decisions or send doctors into a country to investigate the spread of a disease.

WHO's mandate is to direct and coordinate U.N. health policy: It makes recommendations and global assessments on issues including HIV/AIDS, malaria, and tuberculosis, and also coordinates responses to health crises like disease outbreaks and humanitarian disasters. But its recommendations are not binding — and countries are free to disregard WHO's advice.

"WHO is in an incredibly difficult position," said Richard Horton, editor of the Lancet medical journal. "On the one hand, its entire modus operandi is that it responds to government requests. But in this situation, what governments might want may not align with what WHO thinks is best."

Key to containing the illness
Horton cited the 2003 SARS outbreak as a prime example. When the illness began spreading in Toronto, WHO issued a recommendation advising against nonessential travel to Canada's largest city. Similar recommendations were made for cities including Hong Kong, Beijing and Taipei.

The recommendations sharply cut travel to affected economies, dealing them a big economic blow — but the aggressive WHO action was credited with being key to containing the illness.

The advisory incensed Canada, and Toronto's then-mayor publicly lambasted the agency, declaring it had no right to issue such guidelines. A delegation of Canadian diplomats and journalists flew to Geneva and camped out at WHO's Geneva headquarters, forcing the agency to reconsider — and eventually lift — the advisory.

"I suspect the reason WHO has been very reluctant to make any comments about travel (during the swine flu outbreak) is because of that experience with Canada during SARS," said Horton.

By issuing the controversial advisories, WHO's director-general at the time, Gro Harlem Brundtland, proved she was ready to confront countries.

Current chief both praised and criticized
WHO's current chief, Margaret Chan, has been both praised and criticized for her less confrontational leadership — which only recently helped to end a decades-long standoff between China and Taiwan to allow the island to participate in global health meetings. Critics contend that her unwillingness to publicly pressure member states can undermine efforts to protect global health.

Notably, Chan has come under scrutiny for being publicly neutral over Indonesia's refusal to share bird flu samples with the scientific community — which leaves a gaping hole in experts' ability to see how bird flu is evolving.

"Indonesia's behavior isn't helpful, but WHO did not confront them about it," said Adam Kamradt-Scott, a global health governance expert at London's School of Hygiene and Tropical Medicine. He said Chan, as the head of WHO, can only do what her member states allow her to do.

"Avoiding open fights is kind of the sine qua non of working for an international organization," Dr. Jeffrey Koplan, an ex-director of the U.S. Centers for Disease Control and Prevention. "But when it comes to protecting public health, I don't think she would hesitate for a second to do whatever is necessary, including being at odds with a WHO member state."

Koplan said chastising countries publicly can only lead to "short-term victories" and that it is essential for the WHO chief to keep open channels of communication with all countries.

WHO'S flu chief, Dr. Keiji Fukuda, insists the agency's discussions on how to react to outbreaks are "focused purely" on medical issues, such as how the disease is being transmitted.

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