For the record
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## Pandemic unpreparedness

The world remains woefully unprepared to handle a flu pandemic, as evidenced by shortcomings witnessed during pandemic (H1N1) 2009, according to a expert panel struck to review the World Health Organization’s handling of the swine flu outbreak.

That’s compounded by the lack of progress in implementing the International Health Regulations (IHRs), leading to the inescapable conclusion that the globe is not adequately prepared to deal with a pandemic, according to the *Report of the Review Committee on the Functioning of the International Health Regulations (2005) and on Pandemic Influenza A (H1N1) 2009* ([www.who.int/ihr/preview\_report\_review\_committee\_mar2011\_en.pdf](http://www.who.int/ihr/preview\_report\_review_committee_mar2011_en.pdf)). “The unavoidable reality is that tens of millions of people would be at risk of dying in a severe global pandemic.”

“The core national and local capacities called for in the IHR are not yet fully operational and are not now on a path to timely implementation worldwide,” the report states. “Despite these positive features of the IHR, many States Parties lack core capacities to detect, assess and report potential health threats and are not on a path to complete their obligations for plans and infrastructure by the 2012 deadline specified in the IHR. Continuing on the current trajectory will not enable countries to develop these capacities and fully implement the IHR. Of the 194 States Parties, 128, or 66%, responded to a recent WHO questionnaire on their progress. Only 58% of the respondents reported having developed national plans to meet core capacity requirements, and as few as 10% of reporting countries indicated that they had fully established the capacities envisaged by the IHR. Further, as documented by external studies and a WHO questionnaire, in some countries, National IHR Focal Points lack the authority to communicate information related to public health emergencies to WHO in a timely manner.

The most important structural shortcoming of the IHR is the lack of enforceable sanctions. For example, if a country fails to explain why it has adopted more restrictive traffic and trade measures than those recommended by WHO, no legal consequences follow.”

Among a series of remedial recommendations urged by the panel are the creation of a minimum US$100 million contingency fund for public health emergencies; the establishment of “a more extensive global, public health reserve corps” to be deployed in countries that request help during emergencies; and negotiation of an international agreement on equality of access to vaccines and the sharing of viruses for research purposes. The report urges that “all vaccine manufacturers should commit to a contribution of 10% of pandemic influenza vaccine from each production run to a global redistribution pool.”

The expert panel, chaired by Dr. Harvey Fineberg, president of the United States Institute of Medicine, was struck in response to allegations from the Council of Europe and various groups and medical journals that the WHO had mishandled the pandemic, in part because it was relying heavily on the advice of physicians or researchers who had ties to pharmaceutical interests with a vested interest in selling vaccines.

Its conclusion on the conflict of interest issue? “WHO performed well in many ways during the pandemic, confronted systemic difficulties and demonstrated some shortcomings. The Committee found no evidence of malfeasance.”

But while commending aspects of the WHO’s handling of the pandemic, the panel identified 13 systemic difficulties and shortcomings. Those included “the absence of a consistent, measurable and understandable depiction of severity of the pandemic.”

The panel also found WHO’s “phase structure” for determining and classifying pandemics to be “needlessly complex. The multi-phase structure contains more stages than differentiated responses. Defined phases leading to a pandemic are more useful for planning purposes than for operational management.”

With regard to conflict of interest, the panel stated that WHO lacks “a sufficiently robust, systematic and open set of procedures for disclosing, recognizing and managing conflicts of interest among expert advisers. In particular, potential conflicts of interest among Emergency Committee members were not managed in a timely fashion by WHO. Five members of the Emergency Committee and an Adviser to the Emergency Committee declared potential conflicts of interest. None of these were determined sufficiently important to merit the members’ exclusion from the Emergency Committee. The relationships in question were published, along with the names of the members of the Emergency Committee, when the pandemic was declared over on 10 August 2010. Before this information was published, however, assumptions about potential ties between Emergency Committee members and industry led some to suspect wrongdoing. The Review Committee recognizes that WHO is taking steps to improve its management of conflicts of interest, even as this review has proceeded.”

“As far as the Review Committee can determine, no critic of WHO has produced any direct evidence of commercial influence on decision-making,” added the report. — Wayne Kondro, *CMAJ*

## The new professionalism

Nearly 20% of British and American doctors have had an experience with an “impaired or incompetent” colleague in the past three years but in a third of those instances, did not report them to authorities, according to a survey on the professional values and behaviours of doctors.

“The commonest action taken by US doctors with knowledge of an impaired or incompetent colleague was to stop referring patients to that doctor — an action much less commonly reported by UK doctors (17.2% UK, 72.4% US, p<0.001). Where doctors had not reported an impaired colleague to the authorities, the commonest reasons given were because they thought someone else was taking care of the problem (25.7% UK, 20.1% US, p=0.70), because they were afraid of retribution (34.2% UK, 12.4% US, p=0.17), or because they thought nothing would happen (14.3% UK, 15.9% US, p=0.83),” according to the survey, which was led by the Cambridge Centre for Health Services Research ([http://press.psprings.co.uk/qs/march/qs48173.pdf](http://press.psprings.co.uk/qs/march/qs48173.pdf)).

“UK doctors were more likely than US doctors to agree that significant medica errors should always be disclosed to patients. More US doctors reported that they had not disclosed an error to a patient because they were afraid of being sued,” it added.

The survey of 1891 US and 1078 UK doctors also found that roughly 80% of doctors in both countries agreed with the proposition that “doctors should put patients’ welfare above the doctor’s own financial interests.”

“UK doctors were less likely [than] those in the US to agree that all the benefits and risks of a procedure should be explained to the patient (‘completely agree’ UK 73.8% vs 88.4% US p<0.001). However, when things went wrong, UK doctors were significantly more likely than their US counterparts to agree that significant medical errors should always be disclosed to affected patients (completely agree 70.2% UK vs 63.5% US, p=0.04).”

About two thirds of both UK and US doctors agreed with the notion that “doctors should disclose their financial relationships with drug/medical device companies to their patients.” Some 83.3% of US doctors and 73.2% of UK doctors said they’d received a gift from a pharmaceutical firm in the previous year.

The survey also indicated “over 90% of doctors in both countries reported that their behaviour had been altered by clinical guidelines in the previous 3 years, but doctors in the UK were much more likely to have participated in the development of clinical guidelines.”

As well, the survey found that 92.1% of US doctors and 91.7% of UK doctors agreed with the proposition that “sexual relationships with patients are ‘never appropriate’.” — Wayne Kondro, *CMAJ*

## Priority medicines for maternal and child health

The World Health Organization (WHO) has crafted its first “Top 30” list of priority medicines for maternal and child health that if made available in the developing world, would substantially reduce death tolls.

An estimated 1000 women die each day because of complications during pregnancy and childbirth, and an estimated eight million children die each year because of conditions “that could be prevented or treated with access to simple, affordable medicines,” the WHO says in its report, *Priority medicines for mothers and children 2011*. “However, the availability of medicines at public-health facilities is often poor.”

“We know that basic, cheap oral rehydration salts and zinc stop children from dying from diarrhoea, and we recommend that all countries make them accessible. But our surveys show that, at present, ORS [Oral Rehydration Salts] is available in less than half of pharmacies and kiosks in African countries and zinc is not available at all in many places. This list is designed to help countries prioritize, so that they focus on getting the most critical things available and save the most lives,” Dr. Elizabeth Mason, director of the WHO’s department of maternal, newborn, child and adolescent health, said in a news release ([www.who.int/mediacentre/news/notes/2011/mother\_child\_medicine\_20110321/en/index.html](http://www.who.int/mediacentre/news/notes/2011/mother_child_medicine_20110321/en/index.html)).

The WHO also urged that medicines for children be provided in easy-to-measure and easy-to-take doses. “Medicines produced in liquid form are more expensive than tablets or powders and are also more difficult to store, package, and transport, due to their bulk, weight and need for refrigeration. The list we have drawn up tells manufacturers exactly what they should be producing to meet countries needs,” said Dr. Hans V. Hogerzeil, director of WHO’s department for essential medicines and pharmaceutical policies.

The medicines were chosen by a panel of experts “according to 1) the global burden of disease; 2) the evidence of efficacy and safety for preventing or treating major causes of sexual and reproductive, maternal, newborn and child mortality and morbidity. In addition, medicines were included for the prevention of pre-term birth and palliative care,” the WHO noted.

The medicines chosen included oxytocin and “injectable” sodium chloride or sodium lactate compound solution for obstetric hemorrhage, which is estimated to cause 127 000 deaths annually (for the full list, see [www.who.int/childmedicines/prioritymedicines/priority\_medicines\_mothers\_children\_a4.pdf](http://www.who.int/childmedicines/prioritymedicines/priority\_medicines_mothers_children_a4.pdf)). — Wayne Kondro, *CMAJ*

## Most Canadians get priority surgery on time

Some 8 out of 10 Canadians are receiving priority surgical procedures, such as hip replacements and cancer radiation treatment, within recommended wait times, according to a new study from the Canadian Institute for Health Information (CIHI).

But the study, *Wait Times in Canada: a Comparison by Province, 2011*, also indicates that the likelihood of receiving treatment within the recommended time frame continues to “vary considerably” depending on where a patient lives in Canada, and that reductions in wait times have not been seen across all priority procedures or provinces ([http://secure.cihi.ca/cihiweb/products/Wait\_times\_tables\_2011\_en.pdf](http://secure.cihi.ca/cihiweb/products/Wait\_times_tables_2011_en.pdf)).

Following “intense media coverage and public debate” around wait times, Canada’s health ministers agreed to the following benchmarks for priority procedures in 2005:

*   “Hip replacements within 26 weeks;

*   Knee replacements within 26 weeks;

*   Surgical repair of hip fracture within 48 hours;

*   Surgery to remove cataracts within 16 weeks for patients who are high risk;

*   Cardiac bypass surgery within 2 to 26 weeks, depending on how urgently care is required; and

*   Radiation therapy to treat cancer within four weeks of patients been ready to treat.”

CIHI estimates that 83% Canadians received cataract surgery, 84% received hip replacements and 98% received radiation treatment within the desired time frame in 2010. The proportion of patients who received hip fracture repairs and knee replacements within the recommended wait time was lower, at 78% and 79%, respectively.

But wait times for knee replacement and cataract surgery varied widely from province to province. The proportion of patients who received knee replacements within the acceptable six-month waiting period ranged from 42% in Nova Scotia to 89% in Ontario, while the percentage of patients who received cataract surgery within the recommended 16 weeks ranged from 48% in Alberta to 89% in New Brunswick.

Smaller differences existed between the provinces for other priority procedures. Between 78% (Saskatchewan) and 82% (Manitoba) of patients received hip fracture repairs within the benchmark wait time, while 85% (Nova Scotia) to 100% (Manitoba) of patients received radiation treatment within the recommended four weeks.

“The good news is that the majority of Canadians are now getting priority area procedures within recommended wait times,” Jeremy Veillard, CIHI’s vice president of research and analysis, said in a press release ([www.cihi.ca/CIHI-ext-portal/internet/en/Document/health+system+performance/access+and+wait+times/RELEASE_21MAR11](http://www.cihi.ca/CIHI-ext-portal/internet/en/Document/health+system+performance/access+and+wait+times/RELEASE_21MAR11)).

The study also indicates that improvements to wait times for some procedures have yet to been realized in some provinces. For example, over the last three years, seven of the nine provinces for which data was available showed no change or a decrease in the percentage of patients who received knee replacement surgery within the benchmark time frame. Only New Brunswick and Saskatchewan showed improvements. Likewise, only Prince Edward Island, New Brunswick and Saskatchewan showed improvements in the proportion of patients receiving cataract surgery within the benchmark, while other provinces reported unchanged or increasing wait times.

Moreover, none of the provinces reported improvements over the last year in the percentage of patients who underwent radiation treatment within the benchmark time.

That study suggests that achieving 100% treatment levels for all benchmarks “may not be achievable or practical” for various reasons, including that patients may postpone surgeries because of “other illnesses or complications” or for “personal reasons, such as waiting for a family member to assist with post-surgical convalescence.” — Lauren Vogel, *CMAJ*