Public health authorities responded well in the face of the H1N1 flu pandemic but must learn to be more flexible and transparent, Zsuzsanna Jakab, WHO regional director for Europe, told EURACTIV in an interview.
Zsuzsanna Jakab is regional director for Europe at the World Health Organisation.
She was speaking to Gary Finnegan
What are the lessons learnt from the H1N1 flu pandemic?
The pandemic goes on, however, the emergency committee which advises Margaret Chan [WHO director-general] will meet at the end of the month to decide whether to scale it back to a post-pandemic phase. We all expect this to happen sooner rather than later, probably by the end of July.
The first lesson is that we did very well, saving many lives and containing the pandemic through intensive activity. On the other hand, we have three lessons: whilst preparing for a worst-case scenario, we should have an in-built flexibility to scale-back our activities if the pandemic proves milder than expected. We did not have this scenario in the guidelines as they were based on previous 'tough' pandemics and not even the best experts expected the pandemic to be as mild as it was.
The other lesson is that we must do much better in the area of communication; we were not good at that. We must also learn from those who worked against us. We need to use social networks better, having coordinated messages.
Coordination is also always something one can improve. Public health measures like vaccination and anti-virals could also be led by the WHO. This is something we can lead on – rather than the EU institutions – because of our broader, open and easy mandate,
At the moment the WHO has a pandemic alert on a scale of six phases. Do you think a more subtle and complicated instrument will come out of its review?
An International Health Regulation Review Committee has been convened by the WHO director-general to review the lessons learned and the guidelines to the pandemic phases, as well as the criteria for determining them. At present the guidelines only take into account the geographical spread of a virus and not its severity.
We expect a full report on this by the end of the year to guide our work and to have a unique opportunity to move on to the next stage of pandemic preparation.
How do you assess the European institutions' response to the pandemic?
I think they did a good job – I was the ECDC [European Centre for Disease Prevention and Control] director at that time! There was criticism that the ECDC blindly followed the WHO risk assessment, which was not true. ECDC did its own assessment which coincided with that of the WHO. This is why the Commission recommended following the WHO's guidelines.
I think the ECDC did everything it could. We can all do better, however, such as improving surveillance and involving other specialists and professionals in risk assessments to deal with different scenarios. The conference that took place before the Council meeting highlighted a number of conclusions for improvement.
The ECDC and the Commission enjoy very good cooperation, but risk management issues are strictly national responsibilities and it is very difficult to coordinate 27 member states with very strong views on public health measures.
One of the difficulties was therefore that different countries took different measures. There were different approaches on who to vaccinate, how many vaccines to buy, and who should get anti-virals such as Tamiflu.
All this is known by the general public, but they don't understand why these differences exist. I believe that the WHO should strengthen its activities where the EU has difficulties with its mandate.
There has been some criticism of the response, mostly from people concerned about the volume of vaccines that some member states bought. Do you think that some of them overreacted, given that others didn't buy such a high volume of medicines?
It is a difficult issue, because to boost vaccine production in the pharmaceutical industry it was important that some member states made this pre-pandemic purchase agreement to show industry that a market for the vaccines exists. Without this, vaccine production would not have started.
We should learn from this for the future and go towards joint procurement and to have a scaled plan for every country with a number of percentages to buy for the high priority population to be vaccinated and then, if there is a need, expand production.
I suppose those decisions have to be made before it is known how severe the pandemic is. Concerning the alleged conflicts of interest for some of the experts advising the WHO, what is your position on this?
My position is that the reason why this came up is because the Emergency Committee advising on the pandemic phases is composed of experts from all over the world selected by the WHO director-general. It had been deliberately decided that the experts would not be named by the WHO. This is in order to avoid these experts coming under pressure from politicians and the pharmaceutical industry.
We agreed to announce their names only when they have finished their work for the WHO. It is a deliberate decision made after the SARS epidemic, which nonetheless creates a lot of speculation.
Now that it has created so many problems, we must reconsider whether it is still the right approach. We have the same policy as the EU on issues of conflict of interest and every expert must declare their interests. These declarations will now be made far more public as part of new procedures put in place.
You've just been to the informal Health Council. What were the main issues being discussed there?
I was talking about two issues: the role of the WHO in stepping up cancer efforts and the leadership role, and the other one is the H1N1 pandemic and what lessons have been learnt from it.
What are your other priorities for your time as WHO regional director for Europe?
My main priority is the NCDs – chronic non-communicable diseases – together with health-determinant lifestyle issues. Within that we must continue to scale-up our work on smoking, as it is the main cause of many cancer deaths and also cardiovascular disease.
We intend to come forward with an alcohol policy and to strengthen our activity in the fields of obesity and physical activity.
Parallel to this we need to continue with the social determinants, the underlying root causes for much ill-health in Europe. For this reason we are doing a European study as the basis for a renewed European health policy I plan to develop in collaboration with member states and have it adopted next year so that it can be a source of inspiration for them.
I also want to reach out to the environment and educational sectors and how to finance social policy. Prevention is also always important!
I presume health inequality will be a big part of this across Europe. What can the WHO do in this regard, apart from 'inspiring' action in member states? Do you have powers in this area?
We have a lot. We have a very open mandate and so our hands are not bound by complex competency issues. In this regard it's easier to be in the WHO than the EU institutions.
Our definition of health is very broad as it doesn't just cover the absence of disease but also social and mental wellbeing, giving us a mandate on every issue that impacts on health and to reach out to other sectors.
We have a very strong convening power that we should use as much as we can. For example, during the financial crisis many countries are making healthcare sector cuts and the WHO should be leading on this.
My intention is also to bring partnerships together so as not to duplicate the work of the EU and only to work in new areas if the EU doesn't have a mandate or if we can bring added-value.
Concerning the response to the financial crisis, will you be pushing governments to consider the impacts of cutting social expenditure?
Many governments are having to cut back on health expenditure, which means putting things into a long-term perspective. You should not cut back on health and prevention and immunisation programmes etc. as that would make Europe very vulnerable, but we should make the institutional system more streamlined.
Concerning Europe and health policy, the European Parliament is currently debating counterfeit medicines. Do you have a position on this issue?
Counterfeit medicines was on the agenda of our recent assembly in Geneva. We adopted a resolution on this and the WHO must be involved. I will take it up with the member states in September in our regional committee.
There has been some criticism from Health Action International on the IMPACT initiative of the WHO, saying that the WHO shouldn't be involved in something that's about protecting the intellectual property of big companies. What's your response to that?
We've discussed that. I was not very much aware of this before as the Secretariat for this is in Geneva. We had agreed that the WHO be involved in public health aspects of this rather than law enforcement side. Therefore the secretariat is currently within the WHO but the director-general has said she will look at whether someone else can take it over. That's going ahead.
What can Europe do to reduce global health equalities? Do you think it will continue to grow with the expansion of technologies in health care?
Europe must take leadership on this through humanitarian aid and supporting the Millennium Development Goals. European countries greatly contribute to the WHO budget and thus have a role to say which priorities to invest in.
The EU Global Health initiative is something we fully support as the EU institutions also play a big role in this. I believe that we need a coordinated approach from Europe to address health equalities.
I have an agenda item – Health and Foreign Policy – under the WHO Regional Committee for Europe saying that health is so global and yet so regional these days that many decisions are not made at national level and therefore need to be linked.
WHO Europe represents 53 countries. What are the priorities for the non-EU countries?
The first priority is still the non-communicable diseases and health security. We are seeing this especially now in Tajikistan with the polio outbreak, which is my number one priority. We have been conducting immunisation campaigns there. As a result, there are no new AFP cases.
We do the same in all the central Asian countries where the virus may have been imported and are working with Russia. Now I will also start working with Ukraine where I see a problem with immunisation. There is a gap to be addressed in immunisation there.
Measles and rubella are also a priority but I want to extend the deadline for its elimination from 2010 to 2015 as it is for the whole WHO European region. Also, multi-drug resistant TB is a huge threat. Out of the 27 high-burden countries worldwide, 15 are in Europe, mostly in eastern Europe but including the Baltics. Resistance to antibiotics is also important.
Beyond infectious diseases are the underlying weaknesses in the health system, such as surveillance, public health systems, access and affordability.
What is the current status of the pandemic? Has it continued to decline?
In Europe it has. In the Southern hemisphere you still see a few cases, which is why it is yet to be scaled back to a post-pandemic phase. As autumn and winter will soon come, influenza will return however. This is why the new seasonal flu vaccine will include a H1N1 component. It will be given mainly to the elderly and the chronically ill.
Some say that there is a risk that H1N1 will mutate and come back stronger. Are we guarding against this?
We always have this risk, unfortunately, because influenza viruses are very unstable, so this possibility always exists.