Sunday, June 29, 2008

Who needs the WHO?

TAIPEI, Taiwan--The country is in the midst of an outbreak of enterovirus 71 that is affecting young children. There is no need for a scientific definition of an outbreak. It is simply an increase in the number of cases compared to what is normally observed. In 2006 and 2007, enterovirus cases did not spike past 5 in any month for the entire year. For 2008, figures have already shot past 30 for the summer months. In the previous 2 years, no cases were reported until May, whereas cases started showing up this January. There have been 260 cases so far, and the death toll now stands at 9. The latest victim was a 4-month-old girl from Yunlin County, who died in just 5 days.

Ten years ago, there was widespread panic when many children started to develop skin rashes, with some of them dying quickly. It turned out to be the first outbreak of enterovirus 71, and the lag in knowing the causative agent was detrimental. Weeks went by before the US CDC arrived in Taiwan to help with prevention efforts and put pressure on the WHO to get involved. The 1998 outbreak resulted in 78 deaths, almost all of them under the age of 5. Among the survivors, there were 405 cases of serious complications involving neurological damage. Given that smaller outbreaks had occurred nearby in Singapore and Malaysia, being part of the larger public health community may have lessened the damage.

Unfortunately, Taiwan has had to rely on informal contacts with the WHO and US CDC since China took its UN seat in 1972. Efforts to become an official member of the WHO or even just an observer in the World Health Assembly (the decision-making body) have been blocked. Furthermore, the MOU signed in 2005 between the WHO and China limits the amount of contact Taiwan has with the organization. China filters all the information that is trickled down to us. Taiwanese citizens are restricted from joining expert panels. The Chinese decide which Taiwanese members are invited to meetings, and both sides must be present at all times. Essentially, the WHO has hired China as our booking agent.

Despite all this, Taiwan has chosen to be a responsible member of the global community by voluntarily complying with the WHO’s International Health Regulations (IHR) that went into effect last year. The IHR puts obligations on countries to reduce the threats of infectious diseases by participating in a worldwide system to disseminate information on outbreaks. In addition, Taiwan has been involved with medical humanitarian efforts to its allies in Africa and provided aid to Indonesia after the tsunami in 2004 and to Burma after the recent cyclone. In response to the Szechuan earthquake, Taiwan sent in a rescue team on its own. After the 9-21 earthquake that killed more than 2,000 people in central Taiwan, emergency rescue efforts were delayed because teams could not pass through Chinese airspace.

Aside from engaging in petty political maneuvers, the Chinese government has proven that it has a hard time caring for the health of its own citizens. The SARS pandemic 5 years ago was the direct result of a delay in Beijing's disclosures about the disease. Among its rural areas, unsafe practices of organ selling and blood selling are rampant. The number of AIDS cases is grossly underestimated, in part due to the detainment of many AIDS activists.

The current Director-General of the WHO is Dr. Margaret Chan, who hails from China and has served as head of Hong Kong’s Department of Health. Earlier this year for fear of a flu outbreak, Hong Kong closed its schools for 2 whole weeks. An infectious disease attack on the children in her home country would have been embarrassing. Likewise, Taiwan is unlikely to make any progress on its entry into the WHO before Chan’s term ends in 2012.

As the highest international health authority, the WHO’s role is based largely on controlling outbreaks. With the ease of global travel, everyone needs to be part of the public health system. This becomes an even bigger issue now that Chinese tourists are expected to come to Taiwan in large numbers. However, while outbreaks are sporadic and part of nature’s ebb and flow, the WHO has other responsibilities to negotiate prices for drugs and vaccines, commission research on the latest technologies and make health-related recommendations and policies. Unfortunately, all too often Taiwan’s status has become a political question, not a legal or even professional one.

In response to the recent outbreak of enterovirus, the new Minister of Health Lin Fang-yu (林芳郁) was heavily criticized and eventually apologized for saying that all we could do was pray. In its reasoning for rejecting Taiwan’s application yet again, the WHA cited that China was responsible for the health of the 23 million Taiwanese citizens. Now, THAT should give us religion.

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