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.
Consequences of raising global alert level
But he conceded in a press conference this week that the agency's experts are "very aware" that raising the global alert level has quite significant political and potentially economic implications for all countries."
He added that Chan "did listen to all of these considerations but the main focus and most of the discussions really focused on what do we know about the epidemiology and what can we infer about it."
Many international health experts doubt whether granting WHO enhanced powers to fight disease would make a difference to curbing international disease threats. And most member nations bristle at the idea.
A delegate from an Asian country that has faced bird flu outbreaks said he did not want more powers for WHO than those granted by the International Health Regulations, which require countries to report major disease outbreaks and public health events to WHO.
He spoke on condition of anonymity because he was not authorized to speak to the press.
WHO can request information from countries about rumored or suspected outbreaks, but it cannot unilaterally enter a country to respond to a health crisis without an invitation from the government.
Time to expand WHO's powers?
Some have wondered whether it's time to grant WHO such powers when faced with potential health catastrophes that may cross borders.
"Some countries might support that idea, but the problem is how to do it in reality," said Sandra Mounier-Jack, a global public health policy expert at the London School of Hygiene and Tropical Medicine.
When investigating outbreaks, WHO doctors rely on governments to help track down cases and strengthen surveillance systems. Mounier-Jack said it would be almost impossible for WHO to conduct these kinds of investigations if countries were not willing to work with WHO.
"Countries have to feel that WHO is there to help them, not to punish them," she said. "Many countries require visas for entry, so WHO could not just go in without their authorization."
Mounier-Jack suggested that instead of giving WHO more power, the agency could put pressure on countries via the media and the global community. She said it wasn't ideal, but that it had worked in the past, citing the SARS outbreak.
When China hid cases during that outbreak, WHO had no way of forcing the country to come clean, except by loudly voicing their concerns in the press. That eventually worked, and China agreed to allow in WHO teams to help stop the epidemic.