domingo, 6 de junio de 2010

"CONFLICTO DE INTERESES: OMS y conspiraciones de la gripe pandémica"

Artículo del British Medical Journal que explica sobre conflictos de intereses no declarados de expertos de la OMS que dirigieron las políticas en torno a la Pandemia... otra vez las farmacéuticas contaminan las decisiones de la Salud Pública en pos de su beneficio económico.


Published 3 June 2010, doi:10.1136/bmj.c2912
Cite this as: BMJ 2010;340:c2912


Conflicts of Interest

WHO and the pandemic flu "conspiracies"

Deborah Cohen, features editor, BMJ, Philip Carter, journalist, The Bureau of Investigative Journalism, London

Key scientists advising the World Health Organization on planning for an influenza pandemic had done paid work for pharmaceutical firms that stood to gain from the guidance they were preparing. These conflicts of interest have never been publicly disclosed by WHO, and WHO has dismissed inquiries into its handling of the A/H1N1 pandemic as "conspiracy theories." Deborah Cohen and Philip Carter investigate

Next week marks the first anniversary of the official declaration of the influenza A/H1N1 pandemic. On 11 June 2009 Dr Margaret Chan, the director general of the World Health Organization, announced to the world’s media: "I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose. On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met...The world is now at the start of the 2009 influenza pandemic."

It was the culmination of 10 years of pandemic preparedness planning for WHO—years of committee meetings with experts flown in from around the world and reams of draft documents offering guidance to governments. But one year on, governments that took advice from WHO are unwinding their vaccine contracts, and billions of dollars’ worth of stockpiled oseltamivir (Tamiflu) and zanamivir (Relenza)—bought from health budgets already under tight constraints—lie unused in warehouses around the world.

A joint investigation by the BMJ and the Bureau of Investigative Journalism has uncovered evidence that raises troubling questions about how WHO managed conflicts of interest among the scientists who advised its pandemic planning, and about the transparency of the science underlying its advice to governments. Was it appropriate for WHO to take advice from experts who had declarable financial and research ties with pharmaceutical companies producing antivirals and influenza vaccines? Why was key WHO guidance authored by an influenza expert who had received payment for other work from Roche, manufacturers of oseltamivir, and GlaxoSmithKline, manufacturers of zanamivir? And why does the composition of the emergency committee from which Chan sought guidance remain a secret known only to those within WHO? We are left wondering whether major public health organisations are able to effectively manage the conflicts of interest that are inherent in medical science.

Already WHO’s handling of the pandemic has led to an unprecedented number of reviews and inquiries by organisations including the Council of Europe, European Parliament, and WHO itself, following allegations of industry influence. Dr Chan has dismissed these as "conspiracies," and earlier this year, during a speech at the Centers for Disease Control and Prevention in Atlanta, she said: "WHO anticipated close scrutiny of its decisions, but we did not anticipate that we would be accused, by some European politicians, of having declared a fake pandemic on the advice of experts with ties to the pharmaceutical industry and something personal to gain from increased industry profits."

The inquiry by British MP Paul Flynn for the Council of Europe Parliamentary Assembly—due to be published today—will be critical. It will say that decision making around the A/H1N1 crisis has been lacking in transparency. "Some of the outcomes of the pandemic, as illustrated in this report, have been dramatic: distortion of priorities of public health services all over Europe, waste of huge sums of public money, provocation of unjustified fear amongst Europeans, creation of health risks through vaccines and medications which might not have been sufficiently tested before being authorised in fast-track procedures, are all examples of these outcomes. These results need to be critically examined by public health authorities at all levels with a view to rebuilding public confidence in their decisions."

The investigation by the BMJ/The Bureau reveals a system struggling to manage the inherent conflict between the pharmaceutical industry, WHO, and the global public health system, which all draw on the same pool of scientific experts. Our investigation has identified key scientists involved in WHO pandemic planning who had declarable interests, some of whom are or have been funded by pharmaceutical firms that stood to gain from the guidance they were drafting. Yet these interests have never been publicly disclosed by WHO and, despite repeated requests from the BMJ/The Bureau, WHO has failed to provide any details about whether such conflicts were declared by the relevant experts and what, if anything, was done about them.

It is this lack of transparency over conflicts of interests—coupled with a documented changing of the definition of a pandemic and unanswered questions over the evidence base for therapeutic interventions1—that has led to the emergence of these conspiracies.

WHO says: "Potential conflicts of interest are inherent in any relationship between a normative and health development agency, like WHO, and a profit-driven industry. Similar considerations apply when experts advising the Organization have professional links with pharmaceutical companies. Numerous safeguards are in place to manage possible conflicts of interest or their perception."

Another factor that has fuelled the conspiracy theories is the manner in which risk has been communicated. No one disputes the difficulty of communicating an uncertain situation or the concept of risk in a pandemic situation. But one world expert in risk communication, Gerd Gigerenzer, director of the Centre for Adaptive Behaviour and Cognition at the Max Planck Institute in Germany, told the BMJ/The Bureau: "The problem is not so much that communicating uncertainty is difficult, but that uncertainty was not communicated. There was no scientific basis for the WHO’s estimate of 2 billion for likely H1N1 cases, and we knew little about the benefits and harms of the vaccination. The WHO maintained this 2 billion estimate even after the winter season in Australia and New Zealand showed that only about one to two out of 1000 people were infected. Last but not least, it changed the very definition of a pandemic."

WHO for years had defined pandemics as outbreaks causing "enormous numbers of deaths and illness" but in early May 2009 it removed this phrase—describing a measure of severity—from the definition.2

The beginnings

The routes to the Council of Europe’s criticisms can be traced back to 1999, a pivotal year in the influenza world. In April that year WHO—spurred on by the 1997 chicken flu outbreak in Hong Kong—began to organise itself for a feared pandemic. It drew up a key document, Influenza Pandemic Plan: The Role of WHO and Guidelines for National and Regional Planning.

WHO’s first influenza pandemic preparedness plan was stark in the scale of the risk the world faced in 1999: "It is impossible to anticipate when a pandemic might occur. Should a true influenza pandemic virus again appear that behaved as in 1918, even taking into account the advances in medicine since then, unparalleled tolls of illness and death would be expected."

In the small print of that document it states: "R Snacken, J Wood, L R Haaheim, A P Kendal, G J Ligthart, and D Lavanchy prepared this document for the World Health Organization (WHO), in collaboration with the European Scientific Working Group on Influenza (ESWI)." What this document does not disclose is that ESWI is funded entirely by Roche and other influenza drug manufacturers. Nor does it disclose that René Snacken and Daniel Lavanchy were participating in Roche sponsored events the previous year, according to marketing material seen by the BMJ/The Bureau.

Dr Snacken was working for the Belgian ministry of public health when he wrote about studies involving neuraminidase inhibitors for a Roche promotional booklet. And Dr Lavanchy, meanwhile, was a WHO employee when he appeared at a Roche sponsored symposium in 1998. His role at that time was in the WHO Division of Viral Diseases. Dr Lavanchy has declined to comment.

In 1999 other members of the European Scientific Working Group on Influenza included Professor Karl Nicholson of Leicester University, UK, and Professor Abe Osterhaus of Erasmus University in the Netherlands. These two scientists are also identified in Roche marketing material seen by this investigation which was produced between 1998 and 2000. Professor Osterhaus told the BMJ that he had always been transparent about any work he has done with industry. Professor Nicholson similarly has consistently declared his connections with pharmaceutical companies, for example, in papers published in journals such as the BMJ and Lancet.

Both experts were also at that time engaged in a randomised controlled trial on oseltamivir supported by Roche. The trial was subsequently published in the Lancet in 2000.3 It remains one of the main studies supporting oseltamivir’s effectiveness—and one that was subsequently shown to have employed undeclared industry funded ghostwriters.1

The influence of the European Scientific Working Group on Influenza would continue as the decade wore on and the calls for pandemic planning became more strident. Founded in 1992, this "multidisciplinary group of key opinion leaders in influenza aims to combat the impact of epidemic and pandemic influenza" and claims links to WHO, the Robert Koch Institute, and the European Centre for Disease Prevention and Control, among others.4 Despite the group’s claims of scientific independence its 100% industry funding does present a potential conflict of interest. One if its roles is to lobby politicians, as highlighted in a 2009 policy document.5

At a pre-pandemic preparation workshop of the European Scientific Working Group on Influenza in January last year, Professor Osterhaus said: "I can tell you that ESWI is working on that idea [that is, convincing politicians] quite intensively. We have contact with MEPs [members of the European Parliament] and with national politicians. But it is they who have to decide at the end of the day, and they will only act at the request of their constituencies. If the latter are not prompted, nothing will happen."

The group’s policy plan for 2006-10 specifically stated that government representatives needed to "take measures to encourage the pharmaceutical industry to plan its vaccine/antivirals production capacity in advance" and also to "encourage and support research and development of pandemic vaccine" and to "develop a policy for antiviral stockpiling." It also added that government representatives needed to know that "influenza vaccination and use of antivirals is beneficial and safe." It said that the group provided "evidence based, palatable information"; and also "networking/exchange with other stakeholders (eg, with industry in order to establish pandemic vaccine and antivirals contracts)." In the meantime, in Roche’s own marketing plan, one goal was to "align Roche with credible third party advocates". They "leveraged these relationships by enlisting our third-party partners to serve as spokespeople and increase awareness of Tamiflu and its benefits."6

Barbara Mintzes, assistant professor in the Department of Pharmacology and Therapeutics at the University of British Columbia, is currently part of a group working with Health Action International and WHO developing model curricula for medical and pharmaceutical students on drug promotion and interactions with the industry, including conflicts of interest. She thinks that caution is advised when working with medical bodies of this sort.

"It is legitimate for WHO to work with industry at times. But I would have concerns about involvement with a group that looks like it is for independent academics that is actually mainly industry funded," she told the BMJ/The Bureau, adding: "The Institute of Medicine has raised concerns about the need to have a firewall with medical groups. To me this does not sound like an independent group, as it is mainly funded by manufacturers."

She also thinks that there is a difference between the conflict of interest in having a clinical trial funded by a company and the conflict of interest in being involved in marketing a drug—for example, on a paid speaker’s bureau or in marketing material. "Some academic medical departments, for example Stanford University, have banned staff from being involved in marketing or being on a paid speakers bureau," she said.

The presence of leading influenza scientists at promotional events for oseltamivir reflected not just the concern of an impending pandemic, but the excitement over the potential of a new class of drugs—neuraminidase inhibitors—to offer treatment and protection against seasonal influenza.

In 1999 two new drugs first came to market: oseltamivir, from Roche; and zanamivir, manufactured by what is now GlaxoSmithKline. The two drugs would battle it out over the coming years, with oseltamivir—aided by its oral administration—trumping its rival in global sales as the decade wore on.

The potential was quickly grasped. Indeed, that year Professor Osterhaus published an article proposing the use of neuraminidase inhibitors in pandemics: "Finally, during a possible future influenza pandemic, in view of their broad reactivity against influenza virus neuraminidase subtypes and the expected lack of sufficient quantities of vaccine, the new antivirals will undoubtedly have an essential role to play in reducing the number of victims."7

However, he also warned that antivirals should not be seen as a replacement for vaccinations. "Close collaboration and consultation between, on the one hand, companies marketing influenza vaccines and, on the other, those marketing antivirals will therefore be absolutely essential. It is important that a clear and uniform message indicating the complementary roles of vaccines and antivirals is delivered."

That article appeared in the European Scientific Working Group on Influenza’s bulletin of April 1999; Professor Osterhaus signs off with the affiliation of WHO National Influenza Centre Rotterdam, The Netherlands.

Other experts soon followed suit—recommending the role neuraminidase inhibitors could play in any future pandemic—in both the academic literature and in the general media.

Food and Drug Administration

While the excitement over these drugs fuelled scientific symposiums, the US Food and Drug Administration (FDA) was less than convinced. The BMJ/The Bureau has since spoken to people from within the American and European drug regulators, the FDA and the European Medicines Agency (EMEA), who said that both regulators struggled with the paucity of the data presented to them for zanamivir and oseltamivir, respectively, during the licensing process. At the end of last year, the BMJ called for access to raw data for key public health drugs after the Cochrane Collaboration found the effectiveness of the drugs impossible to evaluate.8 The group are continuing to negotiate access to what they say they need to fully assess the effectiveness of antivirals.

In the US, the FDA first approved zanamivir in 1999.9 Michael Elashoff, a former employee of the FDA, was the statistician working on the zanamivir account. He told the BMJ how the FDA advisory committee initially rejected zanamivir because the drug lacked efficacy.

After Dr Elashoff’s review (he had access to individual patient data and summary study reports) the FDA’s advisory committee voted by 13 to 4 not to approve zanamivir on the grounds that it was no more effective than placebo when the patients were on other drugs such as paracetamol. He said that it didn’t reduce symptoms even by a day.

"When I was reviewing the data, I tried to replicate the analyses in their summary study reports. The issue was not of data quality, but sensitivity analyses showed even less efficacy," he said. "The safety analysis showed there were safety concerns, but the focus was on if Glaxo had demonstrated efficacy." Dr Elashoff’s view was that zanamivir was no better than placebo—and it had side effects. And when the FDA medical reviewer made a presentation, her conclusion was that it could either be approved or not approved. It was a fairly borderline drug.

There were influenza experts on the FDA’s advisory committee and much of the discussion hinged on why a drug that looked so promising in earlier studies wasn’t working in the largest trials in the US. One hypothesis was that people in the US were taking other drugs for symptomatic relief that masked any effect of zanamivir. So zanamivir might have no impact on symptoms over and above the baseline medications that people take when they have influenza.

Two other trials—one in Europe and one in Australia— showed a bit more promise. But there was a very low rate of people taking other medications. "So in the context of not being allowed to take anything for symptomatic relief, there might be some effect of Relenza. But in the context of a typical flu, where you have to take other things to manage your symptoms, you wouldn’t notice any effect of Relenza over and above those other things," Dr Elashoff said. The advisory committee recommended that the drug should not be approved.

Nevertheless, FDA management decided to overturn the committee’s recommendation.

"They would feel better if there was something on the market in case of a pandemic. It wasn’t a scientific decision," Dr Elashoff said.

While Dr Elashoff was working on the zanamivir review, he was assigned the oseltamivir application. But when the review and the advisory committee decided not to recommend zanamivir, the FDA’s management reassigned the oseltamivir review to someone else. Dr Elashoff believes that the approval of zanamivir paved the way for oseltamivir, which was approved by the FDA later that year.

European Medicines Agency

In Europe the EMEA was similarly troubled by the evidence for oseltamivir. By early 2002 Roche had sought a European Union-wide licence from the EMEA. It was a lengthy process, taking three meetings of the Committee for Medicinal Products for Human Use as well as expert panels, according to one of the two rapporteurs, Pekka Kurki of the Finnish Medicines Agency. Echoing the Cochrane Collaborations’s 2009 findings6 Kurki told us: "We discussed the same issues that are still discussed today: does it show clinically significant benefits in treatment and prophylaxis of flu and what was the magnitude of the benefits presented in the RCTs? Our assessment and Cochrane’s in 2009 are very similar with regard to the effect size in RCTs. The data show that the effects of Tamiflu were clear but not very impressive.

"What was unclear and is still unclear is what is the impact of Tamiflu on serious complications. Circulating influenza was very mild when Tamiflu was developed and therefore it is very difficult to say anything about serious complications. The data did not clearly show an effect on serious complications—it was not demonstrated by the RCTs."

In documents obtained under the freedom of information legislation, two of the experts who provided opinions during the EMEA licensing process have also featured in Roche marketing material: Annike Linde and Rene Snacken. In Dr Snacken’s EMEA presentation dated 18 February 2002, he discussed the need for chemoprophylaxis and called for the use of oseltamivir during a pandemic. He made his presentation as a representative of the Belgian Ministry of Public Health. At the time Dr Snacken was also "liaison officer" for the European Scientific Working Group on Influenza. He also played a key role in the Belgian government during its pandemic planning, and he later became a senior expert at the Preparedness and Response Unit, European Centre for Disease Prevention and Control. We do not know what, if anything, he declared to the EMEA about his relationship with Roche.

Annike Linde has confirmed in an email that she has had connections with Roche over a number of years. She made a presentation to the EMEA on "influenza surveillance" in her capacity as a representative of the Swedish Institute for Infectious Disease. Again, it is not clear what, if anything, she declared to the EMEA concerning her previous relationship with Roche.

Dr Linde, now the Swedish state epidemiologist, has told the BMJ/The Bureau that she received payments from Roche International in respect of various pieces of work she did for the company until 2002. She has subsequently given occasional lectures for Roche Sweden. All money she has received from Roche was given, Dr Linde says, to the Swedish Institute for Infectious Disease Control.

We asked the scientists whether they declared their relationship with Roche at the time to the EMEA. Neither has answered that question entirely satisfactorily. Dr Snacken has not replied to repeated emails posing this question. Dr Linde responded by telling the BMJ/The Bureau: "We contribute with our expertise to the regulatory agencies when asked. When we do so, a declaration of interest, where e.g. participation at advisory meetings at Roche, is given and evaluated by the regulatory agency." The BMJ/The Bureau requested Linde and Snacken’s declaration of interest statements for the 2002 meeting from the EMEA under the freedom of information act. The EMEA was unable to provide statements for those particular people at that time.

Developing the guidelines

In October 2002 WHO convened a meeting of influenza experts at its Geneva headquarters. Their purpose was to develop WHO’s guidelines for the use of vaccines and antivirals during an influenza pandemic.

Included at this meeting were representatives from Roche and Aventis Pasteur and three experts who had lent their name to oseltamivir’s marketing material (Professors Karl Nicholson, Ab Osterhaus, and Fred Hayden).

Two years later the WHO published a key report from that meeting, WHO Guidelines on the Use of Vaccines and Antivirals during Influenza Pandemics 2004. The specific guidance on antivirals, Considerations for the Use of Antivirals During an Influenza Pandemic, was written by Fred Hayden. Professor Hayden has confirmed to the BMJ/The Bureau in an email that he was being paid by Roche for lectures and consultancy work for the company at the time the guidance was produced and published. He also told us in an email that he had received payments from GlaxoSmithKline for consultancy and lecturing until 2002. According to Prof Hayden: "DOI [declaration of interest] forms were filled out for the 2002 consultation."

The WHO guidance concluded that: "Based on their pandemic response goals and resources, countries should consider developing plans for ensuring the availability of antivirals. Countries that are considering the use of antivirals as part of their pandemic response will need to stockpile in advance, given that current supplies are very limited." Many countries around the world would adopt this guidance.

The previous year Professor Hayden was also one of the main authors of a Roche sponsored study that claimed what was to become one of oseltamivir’s main selling points—a claimed 60% reduction in hospitalisations from flu, which the Cochrane Collaboration was later unable to verify.8

Our investigation has also identified relevant and declarable interests relating to the two other named authors of annexes to WHO’s 2004 guidelines. Arnold Monto was the author of the annexe dealing with vaccine usage in pandemics. Between 2000 and 2004—and at the time of writing the annexe—Dr Monto has consistently and openly declared honorariums, consultancy fees, and research support from Roche, 10 11 12 consultancy fees and research support from GlaxoSmithKline 10 12 13 14; and also research funding from ViroPharma.15

No conflict of interest statement was included in the annex he wrote for WHO. When asked if he had signed a declaration of interest form for WHO, Dr Monto told the BMJ/The Bureau: "Conflict of Interest forms are requested before participation in any WHO meeting".

Professor Karl Nicholson is the author of the third annex, Pandemic Influenza. According to declarations made by Professor Nicholson in the BMJ16and Lancet in 2003,17 he had received travel sponsorship and honorariums from GlaxoSmithKline and Roche for consultancy work and speaking at international respiratory and infectious diseases symposiums. Before writing the annexe, he had also been paid and declared ad hoc consultancy fees by Wyeth, Chiron, and Berna Biotech.

Even though the previous year these declarations had been openly made in the Lancet and the BMJ, no conflict of interest statement was included in the annex he wrote for WHO. Professor Nicholson told the BMJ/The Bureau that he last had "financial relations" with Roche in 2001. When asked if he had signed a declaration of interest form for WHO, Prof Nicholson replied: "The WHO does require attendees of meetings, such as those held in 2002 and 2004, to complete declarations of interest."

Leaving aside the question of what declarations experts made to WHO, one simple fact remains: WHO itself did not publicly disclose any of these conflicts of interest when it published the 2004 guidance. It is not known whether information about these conflicts of interest was relayed privately to governments around the world when they were considering the advice contained in the guidelines.

The year before WHO issued the 2004 guidance, it published a set of rules on how WHO guidelines should be developed and how any conflicts of interest should be handled. This guidance included recommendations that people who had a conflict of interest should not take part in the discussion or the piece of work affected by that interest or, in certain circumstances, that the person with the conflict should not participate in the relevant discussion or work at all. The WHO rules make provision for the director general’s office to allow declarations of interest to be seen if the objectivity of a meeting has been called into question.18

The BMJ/The Bureau has asked WHO for the conflict of interest declarations for the Geneva 2002 meeting and those related to the guidance document itself. WHO told us that the query went directly up to Margaret Chan’s office. "WHO never publishes individual DOIs [declaration of interest], except after consultation with the Office of the Director-General. In this case, we put in a request on your behalf but it was not granted. In more recent years, many WHO committees have published summaries of relevant interests with their meeting reports."

In a BMJ interview (see film on, WHO spokesperson Gregory Hartl reiterated the fact that Dr Margaret Chan, "is very committed personally to transparency." Yet her office has turned down repeated requests for declaration of interest statements and declines to comment on the allegations that authors of the guidelines had declarable interests.

Nevertheless, Prof Hayden told the BMJ/The Bureau: "I strongly support transparency in declarations of interest, in part because this allows those reading documents, particularly ones authored by specific individuals (eg, Annex 5) [the part he wrote], to make their own judgments about the possible relevance of any potential conflicts."

While experts need to work with industry to develop the best possible drugs for illnesses, questions remain about what level of involvement experts with industry ties should have in the formulation of public health policy decisions and guidelines. Professor Nicholson told the BMJ/The Bureau: "The WHO and decision makers must be informed of ongoing developments and research findings to ensure that they are as up to date as possible. Some of the most relevant expertise and information are held by companies or individuals with conflicts of interest. I understand the view that experts with conflicts of interest should not advise governments or organisations such as the WHO. But to exclude such people from discussions could deprive WHO and decision makers of important new information."

But not everyone agrees. Barbara Mintzes is unequivocal about what role they should play. "No one should be on a committee developing guidelines if they have links to companies that either produce a product—vaccine or drug—or a medical device or test for a disease. It would be preferable that there are no financial ties when it comes to making big decisions on public health—for example, stockpiling a drug—and that includes if they have a currently funded clinical trial," she said.

"Ideally, what you want are independent experts who are in the public sector to provide expertise on drugs and vaccines. But they can be hard to find. One solution is consult with the experts who are involved in industry, but not put them on any decision making committee. You need a firewall," she added.

Indeed, Professor Harvey Fineberg, president of the Institute of Medicine and chairman of the panel reviewing WHO’s management of the pandemic, takes a similarly hard line. His own institution went through a detailed review of how they interact with industry and experts with conflicts of interests last year.19 "Sometimes publication of conflict of interests is enough—for example with a journal. But if you are giving expert judgment to influence policy, revealing is not enough," he told the BMJ, referring to the Institute of Medicine’s policy.

WHO also says that it takes conflicts of interests seriously and has the mechanisms in place to deal with them. But what action does it take when a scientist declares a conflict of interest, and when does it judge a scientist to be too conflicted to play a leading role in the formulation of global health policy? Since WHO has not provided us with an answer to this question, we are left to guess.

As it stands, this situation is the worst possible outcome for WHO, according to Professor Chris Del Mar, a Cochrane Review author and expert on WHO’s Strategic Advisory Group of Experts on Immunization group. "If it proves to be the case that authors of WHO guidance which promoted the use of certain drugs were being paid at the same time by the makers of those drugs for other work they were doing for these companies that is reprehensible and should be condemned in the strongest possible terms."

WHO’s endorsement of oseltamivir was not lost on Roche. In an advert placed by the company for the drug in the main conference programme of the European Scientific Working Group on Influenza’s 2005 conference in Malta, it says: "Antivirals will initially be the principal medical intervention in a pandemic situation and Roche is working as a responsible partner with governments to assist in their pandemic planning." The source reference for this is the WHO Global Influenza Preparedness Plan.

Throughout the following years, WHO would appear to have been inconsistent in how it treated conflicts of interest. Updated pandemic plans would continue to be prepared by experts who openly had work funded and acted as consultants to manufacturers of vaccines and antivirals. WHO produced its global influenza preparedness plan in 2005, and in 2006 it constituted an interim Influenza Pandemic Task Force. No public declarations of interest have been made and to date no details have been provided by WHO in response to our requests.

WHO’s stance that it does not publish declarations of interest from its experts is far from consistent. It is undermined, for example, by the position WHO adopts in relation to the Strategic Advisory Group of Experts on Immunization, its standing vaccine advisory body. Here, contrary to its approach to pandemic planning advisers, WHO does publish summaries of declarations of interest.

Emergency Committee

These seeming inconsistencies in WHO’s approach to transparency and its handling of conflicts of interest extend into the workings of the Emergency Committee formed last year to advise the director general on the pandemic. The identities of its 16 members are unknown outside WHO. This secret committee has guided WHO pandemic policy since then—including deciding when to judge that the pandemic is over.

WHO says it has to keep the identities secret to protect the scientists from being influenced or targeted by industry. In a phone call to the BMJ/The Bureau in March, WHO spokesperson Gregory Hartl explained: "Our general principle is we want to protect the committee from outside influences."

The committee advised the WHO director general on phase changes as well as temporary recommendations. According to WHO, When the Emergency Committee met to discuss a possible move to a declaration of a pandemic, the meeting additionally included members who represented Australia, Canada, Chile, Japan, Mexico, Spain, the UK, and the US, eight countries that experienced widespread outbreaks at the time. These national representatives were present to ensure full consideration of the views and possible reservations of the countries expected to bear the initial brunt of economic and social repercussions.

WHO says all members of the Emergency Committee sign a confidentiality agreement, provide a declaration of interests, and agree to give their consultative time freely, without compensation. However, only one member of the committee has been publicly named: Professor John MacKenzie, who chairs it.

This is a troubling stance: it suggests that WHO considers other advisory groups whose members are not anonymous —such as the Strategic Advisory Group of Experts on Immunization—to be potentially subject to outside influences, and it allows no scrutiny of the scientists selected to advise WHO and global governments on a major public health emergency.

Under the International Health Regulations framework, the membership of the Emergency Committee is drawn from a roster of about 160 experts covering a range of public health areas. This framework provides guidelines about how WHO deals with acute public health risks. The BMJ/The Bureau has identified approximately 15 scientists from the International Health Regulations roster with influenza expertise and has emailed them to ask if they were on the Emergency Committee. Under the framework at least some of these scientists are members of the Emergency Committee. Yet because of the confidentiality agreements they have signed, these scientists cannot acknowledge their membership of the committee, putting them in an invidious position.

David Salisbury, chair of WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) committee at the time of the pandemic and a member of the International Health Regulations, says the secrecy has caused problems for his group. "It certainly caused problems for SAGE. Since all of the details of SAGE are in the public domain, there was a perception that it had been SAGE that had given advice about the changing of definitions or the pandemic levels—when we had not done so. SAGE members came in for unfair personal abuse by journalists," he told the BMJ/The Bureau.

"Given the importance of the advice, the transparency of the source of the advice was important. I believe it is necessary to keep confidential the source of advice if revealing details might put individuals at risk, for example when bioterrorism is being discussed. This does not seem to be the case for pandemic flu," he added.

The secrecy of the committee is also fuelling conspiracy theories, particularly around the activation of dormant pandemic vaccine contracts. A key question will be whether the pharmaceutical companies, which had invested around $4bn (£2.8bn, {euro}3.3bn) in developing the swine flu vaccine, had supporters inside the emergency committee, who then put pressure on WHO to declare a pandemic. It was the declaring of the pandemic that triggered the contracts.

The BMJ/The Bureau can confirm that Dr Monto, Dr John Wood, and Dr Masato Tashiro are members of the Emergency Committee.

Although Dr Monto did not answer the question directly, his Infectious Disease Society of America biography states that he is a member.20

Last year, according to figures made public in the US by GlaxoSmithKline, Professor Monto received $3000 speakers fees from the company in the period between the second quarter and the last quarter of 2009. As a national official of the Japanese government, Dr Tashiro says that he must "have nothing concerning conflict of interest with private companies". Dr John Wood works for the UK National Institute for Biological Standards and Control (NIBSC). Dr Wood, like Dr Tashiro, has no personal conflict of interests but he told the BMJ/The Bureau that as part of its statutory role in developing standards for measurement of biological medicines to ensure accurate dosing and carrying out independent control testing to assure their safety and efficacy, the institute must work closely with the pharmaceutical industry. This is made clear on their website.

"The International Federation of Pharmaceutical Manufacturers and Associations has also made publicly available the nature of their close interaction with NIBSC and similar organisations in order to develop influenza vaccines," he said.21

Those who said that they were not on the committee include David Salisbury, Alan Hampson, Albert Osterhaus, Donato Greco, and Howard Njoo. Maria Zambon, from the UK’s Health Protection Agency told the BMJ: "I undertake various advisory roles to WHO. Declaration of interest statements are prepared before undertaking such roles.

"The HPA Centre for Infection, as part of its role in national infectious disease surveillance, provision of specialist and reference microbiology and vaccine efficacy monitoring, works closely with vaccine manufacturers and biotechnology companies."

International Health Regulations review

WHO’s own review into the operation of the International Health Regulations and WHO’s handling of the pandemic is now being conducted by Harvey Feinberg, president of the US Institute of Medicine, and will report its findings next year. Dr Chan and Professor Feinberg have both made clear the need for a thorough investigation. But questions are already arising about how independent the review will turn out to be. According to the International Health Regulations list in our possession, some 13 of the 29 members of the review panel are members of the International Health Regulations itself and one is the chair of the Emergency Committee. To critics that might suggest a somewhat incestuous approach.

Professor Mintzes does not agree with WHO’s explanation that secrecy was needed to protect against the influence of outside interest on decision making. "I can’t understand why the WHO kept this secret. It should be public in terms of accountability like the expert advisory committees. If the rationale of secret membership is not to be unduly influenced, there are other ways of dealing with this through strong conflict of interest provisions," she said.

She also believes that the very nature of allowing a trigger point for vaccine contracts opens the system up unnecessarily to exploitation. "It seems a problem that this declaration might trigger contracts to be realised. There should be safeguards in place to make sure those with an interest in vaccine manufacturers can’t exploit the situation. The WHO will have to look long and hard at this in future," she said.

The number of victims of H1N1 fell far short of even the more conservative predictions by the WHO. It could, of course, have been far worse.. Planning for the worst while hoping for the best remains a sensible approach. But our investigation has revealed damaging issues. If these are not addressed, H1N1 may yet claim its biggest victim—the credibility of the WHO and the trust in the global public health system.

Cite this as: BMJ 2010;340:c2912

Competing interests: PC declares no competing interests. DC has been paid expenses by WHO for giving talks at two conferences.


  1. Cohen D. Complications: tracking down the data on oseltamivir. BMJ 2009;339:b5387.[Free Full Text]
  2. Doshi P. Calibrated response to emerging infections. BMJ 2009;339:b3471.[Free Full Text]
  3. Nicholson KG, Aoki FY, Osterhaus AD, Trottier S, Carewicz O, Mercier CH, et al. Efficacy and safety of oseltamivir in treatment of acute influenza: a randomised controlled trial. Lancet 2000;355:1845-50.[CrossRef][Web of Science][Medline]
  4. European Scientific Working Group on Influenza. About ESWI.
  5. European Scientific Working Group on Influenza. Revised policy plan 2006-2010.
  6. Holmes Report. Tamiflu launch media campaign.
  7. Osterhaus A, de Jong J. Prophylactic role.
  8. Jefferson T, Jones M, Doshi P, Del Mar C. Neuraminidase inhibitors for preventing and treating influenza in healthy adults: systematic review and meta-analysis. BMJ 2009;339:b5106.[Abstract/Free Full Text]
  9. US Food and Drug Administration. FDA approved drugs for influenza.
  10. Monto AS, Gravenstein S, Elliott M, Colopy M, Schweinle J. Clinical signs and symptoms predicting influenza infection. Arch Intern Med 2000;160:3243-7[Abstract/Free Full Text]
  11. Monto AS, Rotthoff J, Teich E, Herlocher ML, Truscon R, Yen HL, et al. Detection and control of influenza outbreaks in well-vaccinated nursing home populations. Clin Infect Dis 2004;39:459-64.[CrossRef][Web of Science][Medline]
  12. Herlocher ML, Truscon R, Elias S, Yen HL, Roberts NA, Ohmit SE, et al. Influenza viruses resistant to the antiviral drug oseltamivir: transmission studies in ferrets. J Infect Dis 2004;190:1627-30.[CrossRef][Web of Science][Medline]
  13. Monto AS, Pichichero ME, Blanckenberg SJ, Ruuskanen O, Cooper C, Fleming DM, et al. Zanamivir prophylaxis: an effective strategy for the prevention of influenza types A and B within households. J Infect Dis 2002;186:1582-8.[CrossRef][Web of Science][Medline]
  14. Herlocher ML, Truscon R, Fenton R, Klimov A, Elias S, Ohmit SE, et al. Assessment of development of resistance to antivirals in the ferret model of influenza virus infection. J Infect Dis 2003;188:1355-61[CrossRef][Web of Science][Medline]
  15. Fendrick AM, Monto AS, Nightengale B, Sarnes M. The economic burden of non-influenza-related viral respiratory tract infection in the United States. Arch Intern Med 2003;163:487-94.[Abstract/Free Full Text]
  16. Cooper NJ, Sutton AJ, Abrams KR, Wailoo A, Turner D, Nicholson KG. Effectiveness of neuraminidase inhibitors in treatment and prevention of influenza A and B: systematic review and meta-analyses of randomised controlled trials. BMJ 2003;326:1235.[Abstract/Free Full Text]
  17. Nicholson KG, Wood JM, Zambon M. Influenza. Lancet 2003;362:1733-45.[CrossRef][Web of Science][Medline]
  18. World Health Organization. Guidelines for WHO guidelines. World Health Organization, 2003.
  19. National Academies. Policy and procedures on committee composition and balance and conflicts of interest for committees used in the development of reports.
  20. Infectious Disease Society of America. Congratulations to the 2009 Society Award Recipients.
  21. International Federation of Pharmaceutical Manufacturers and Associations Influenza Vaccine Supply International Task Force. WHO influenza virus surveillance system and influenza vaccine production. 2008.

lunes, 12 de octubre de 2009

"¿Cómo evaluar los riesgos reales? Psicosis de la gripe, espejo de la sociedad", por Denis Duclos

el siguiente es un texto que publicaron en Le Monde Diplomatique y que habla sobre las repercusiones en la sociedad del manejo mediático y gubernamental de la Pandemia S-OIV.

¿Cómo evaluar los riesgos reales?


El pánico ocasionado por la manipulación mediática sobre los verdaderos riesgos de la gripe A (H1N1), revela la dificultad de tratar el riesgo como una realidad objetiva. Los grandes temores se multiplican fomentados por quienes les sacan provecho. Para los servicios de seguridad de la industria farmacéutica, la ansiedad es un mercado.

por Denis Duclos

Antropólogo, director de investigaciones en el Centre National de la Recherche Scientifique (CNRS). Trabaja especialmente sobre los “grandes miedos” de la sociedad.

Traducción: Mariana Saúl

Hace 26 años surgía una pandemia nueva para el hombre: el sida. Desde entonces se han lanzado al menos cuatro grandes alertas, la última de las cuales concierne a la llamada gripe A (H1N1). Estas patologías presentan varios puntos en común: derivan tanto de vectores desconocidos –el HIV para el sida o la proteína prion de la encefalopatía espongiforme para el “mal de la vaca loca” (ESB)– como de mutaciones inesperadas de virus conocidos; todas provienen de epizootias (propagaciones de enfermedades animales) y, por último, todas pasaron la barrera inmunitaria que separa a las distintas especies y se volvieron contagiosas para los seres humanos.

Asimismo, también las caracterizan importantes diferencias: el sida mató a 25 millones de personas desde 1983 (de ellas, las dos terceras partes en el África subsahariana). Por su parte, hubo 214 muertos desde 1996 por causa de la variante humana del ESB (1) (de los cuales, 168 eran de Gran Bretaña); el síndrome respiratorio agudo severo (SRAS) provocó 916 víctimas entre 2003 y 2009 (casi todos del Sudeste de Asia). A fines de 2008, la gripe “aviar” (H5N1) apenas tenía 248 casos fatales, el 80% de ellos del sudeste asiático.

En cuanto a la gripe A, ahora tan extendida por el planeta –consecuencia de la “mediación” porcina, como todas las gripes pandémicas del pasado–, “sólo” se le atribuyen 1.250 muertes (sin certezas) en ocho meses, o sea claramente menos que la tasa media de una gripe estacional (300.000 decesos anuales en todo el mundo). Lo cual no descarta su letalidad en invierno, ya que los virus de la gripe resisten bien al frío.

Así, hemos pasado de un peligro, que se reveló masivo y duradero, a potenciales riesgos, recurrentes pero aparentemente débiles. Este cambio va de la mano de actitudes muy diferentes en la manera de aprehenderlos: respecto al sida y al ESB, la opinión pública se preocupó por la manera en que las autoridades y todas las partes afectadas subestimaron los peligros, ocultaron realidades preocupantes e intentaron aplazar lo más posible un escándalo inevitable que cuestionaba a personalidades de primer nivel (2).

En cambio, para el SRAS, la gripe aviar y la gripe transmitida al hombre con el nombre “A”, lo que ocurre es más bien lo contrario: las instituciones sanitarias y los poderes públicos son sospechados de alarmismo. Se les reprocha que utilicen cada oportunidad para desviar la atención de la crisis económica, demostrar su poder de intervención, desplegar una prevención desproporcionada respecto de los peligros reales y, finalmente, entrenar a los cuadros de una gestión mundial a la vez mercantilista, autoritaria e higienista de la salud denunciada desde hace tiempo por Rony Brauman (3), sobre todo al decidir campañas de vacunación obligatoria que en los países pobres resulta al menos discutible.

Así pues, el momento parece propicio para evitar caer en una angustia a todos los niveles sin por ello subestimar lo que está en juego, y para intentar distinguir las fantasías del peligro real.

La amplificación de los riesgos de nuevas epidemias es real: según la Organización Mundial de la Salud (OMS) se descubrieron 39 agentes patógenos desde 1967. La población humana es testigo de un rápido crecimiento (casi 1.000 millones de personas más en diez años) y, sobre todo, una concentración urbana inédita: casi 4.000 millones de individuos viven en las ciudades, o sea más del 50% de la población mundial, y el 25% en las grandes ciudades, entre ellos muchos por debajo de la línea de pobreza (1.000 millones de citadinos viven en condiciones precarias, 862 millones de personas no satisfacen el hambre (4) y 2.000 millones sufren carencias de micronutrientes y proteínas).

Los medios de comunicación, distribución y difusión se desarrollaron considerablemente, acarreando una mayor propagación de los vectores de las enfermedades (los mosquitos son excelentes clientes de las líneas aéreas) y una mayor eficacia en la respuesta. Ya en 1918, la gripe llamada “española” (que también presentaba los subgrupos H1N1), probablemente traída de China por un batallón estadounidense, tardó apenas quince días en dar la vuelta a Estados Unidos (gracias a los barcos, autobuses y trenes) y dos meses en extenderse a los campos de batalla. Terminó matando al menos a treinta millones de personas en todo el mundo (quizá mucho más), de las cuales casi la mitad eran de China e India.

Es por eso que resulta inútil pintar un panorama más negro. Como lo advierte el historiador de medicina Patrick Zylberman, “disponemos de conocimientos científicos sobre el virus (…), antivirales y vacunas. Hay antibióticos que permiten tratar las infecciones. Para no hablar de la vigilancia epidemiológica, implementada desde 1995, o los planes de respuesta epidémica previstos, aun cuando no todo sea perfecto” (5). Contrariamente a lo que ocurría a principios del último siglo, y a pesar de la propagación de la crisis económica, la época actual ya no sufre las hambrunas a repetición o los agotamientos asociados a las grandes guerras, lo cual hace que sea más difícil para una infección vencer las defensas inmunitarias. Además, la mayoría de los habitantes del planeta tiene acceso al agua potable, a pesar de las importantes desigualdades. Y, ya que estamos remontándonos en la historia, recordemos que las grandes pestes de mediados del siglo XIV (que se llevaron más de 50 millones de vidas) debieron su virulencia a un conjunto de factores que agravaron la situación: la proliferación de animales portadores ligada a una “política humana” (como la destrucción de los gatos, ¡considerados diabólicos!), aumento demográfico, concentración de poblaciones en las ciudades, mal estado fisiológico debido a la miseria, estado de beligerancia general y crónica, etcétera.

La enfermedad, inducida por la lógica de lo viviente, ha sabido adaptarse a la era de la tecnología. La eficacia inmemorial de los mecanismos de selección nos juega en contra para limitar los antibióticos u otros progresos médicos: en Estados Unidos, uno de cada dos estafilococos dorados no es sensible a la eritromicina, la metilicina, la penicilina ni la tetraciclina; en Francia, la mitad de los neumococos resiste la penicilina (6), etc. Este fenómeno hace más aleatorio el tratamiento de afecciones posgripales y explica en parte las diferencias considerables de la “letalidad” del H1N1 de un país a otro.

Aquí no se necesita ninguna teoría del complot (que impute intenciones asesinas a las instituciones que favorecen y organizan las vacunas, por ejemplo) para admitir que las estrategias humanas de erradicación de enfermedades –objetivos como mínimo benéficos que honran las ciencias médicas–, terminaron sin poder preverla verdaderamente en la maquinaria de las adaptaciones bacterianas y virales que operan desde hace miles de millones de años (7). Reemplazado por la medicina, el hambre del público por los antibióticos –a menudo más teórico que práctico– recién se vio restringido últimamente. Hubo que encontrarse con esa resistencia para concebir la necesidad de elaborar líneas de acción mucho más específicas. A su vez, el hombre debe responder al desafío, lo cual por otra parte puede implicar un retorno a la vacuna (ignorando la resistencia, puesto que se refuerzan las defensas) o un pasaje a las terapias génicas.

Impotencia para tratar el problema de raíz

En lo que respecta a la gripe (vigilada por la OMS desde su creación en 1948), la mutación fue integrada al razonamiento que condujo a vacunas eficaces en grandes porcentajes. Y también puede ser prevista para las formas nuevas. Así, según varios especialistas dignos de confianza –como Robert Webster, Kawaoka Yoshihiro, Albert Osterhaus, Claude Hannoun o Desmond O’Toole (8)–, el verdadero riesgo de las gripes recientemente salidas del “crisol asiático” (es decir, de una vasta región del mundo donde la población rural vive en promiscuidad con los criaderos porcinos y aviares) reside en una combinación de rasgos genéticos del H1N1 (gran contagiosidad/débil mortalidad) y el H5N1 (débil contagiosidad/fuerte mortalidad). Esa probabilidad es pequeña pero, si ocurriera, existiría el peligro –aunque no es seguro– de ligar los dos caracteres típicos y obtener una fuerte mortalidad en un gran número de personas, sobre todo para las poblaciones del Sudeste de Asia.

Es posible entonces entender la creciente agitación de los Estados, cuyo primer deber es proteger a sus poblaciones, y el tono cada vez más enérgico de las instituciones internacionales, preocupadas por la circulación rápida de las enfermedades (5.000 aviones de línea en vuelo permanente; centenas de millones de niños reunidos en las escuelas, etcétera).

No obstante, aunque se debe reconocer una mayor aceptación de las responsabilidades compartidas, también podemos considerar sus aspectos inevitablemente problemáticos. En la actualidad, para ser capaz de frenar la epidemia de una bacteria, una gripe o un resfrío que se ha vuelto peligroso, sin duda hay que implementar un conjunto de obligaciones: cuarentenas y cierre de fronteras, prohibición de reuniones, “confinamientos” domiciliarios, tratamientos obligatorios, etc. Las poblaciones occidentales perdieron el hábito de las medidas coercitivas de masas, como las movilizaciones generales, y se sienten inclinadas a percibir las regulaciones colectivas del comportamiento como atentados a las libertades individuales.

Otra dimensión del problema: las autoridades parecen menos capaces de frenar la aparición de situaciones favorables a la emergencia de nuevas enfermedades que de intervenir a posteriori, obligando a las personas a efectuar controles o campañas de vacunación sobre la base del voluntariado o la obligación. Esta relativa impotencia para tratar el problema desde la raíz no es nuevo: las autoridades europeas o estadounidenses no dominaban las técnicas de preparación de los productos de transfusión sanguínea que –hoy lo sabemos– contribuyeron al desencadenamiento del sida. No lo hicieron mejor cuando se trató de hacer más segura la fabricación de harinas animales; su ingesta por parte de los bovinos favoreció el pasaje de los priones, que posiblemente venían de animales de otras especies.

Las tres últimas grandes alertas cuestionaron la extensión de la crianza industrial deslocalizada de las aves y los cerdos, sin que por ello hicieran progresar la profilaxis (9) tanto en China como en México o en Malasia, e incluso en los países llamados “desarrollados”. Ocurre que el cerdo (o el jabalí, de enorme presencia en Francia) dispone de receptores de los virus aviares y humanos, y puede servir de crisol para combinar ambos: un millón y medio de muertes les fueron imputadas a estos animales durante las pandemias de origen aviar de 1957 (A/H2N2) y 1968 (A/H3N2, que, aunque no se habló de ella, produjo 32.000 muertes en Francia, o sea el doble que la canícula de 2003) (10). No puede descartarse que la brecha entre el bajo nivel de prevención general y la mayor presión ejercida en el comportamiento del público haya podido verse facilitada por la concepción liberal y el laissez-faire que prevalecieron en el mundo desde los ochenta.

Especialista en enfermedades infecciosas y miembro de la Academia de Medicina, el profesor Marc Gentilini se indigna: “El peso que se atribuye a la gripe A es indecente si se lo compara con la situación sanitaria mundial en su conjunto. Es una pandemia de la indecencia. Cuando observo la situación del planeta, siento vergüenza de ver todo lo que se emprende para evitar esta gripe de la que tan poco se sabe” (11), mientras el paludismo mata a un millón de personas “en la indiferencia cuasi general”. Por no hablar de enfermedades como la diabetes, ejemplo canónico en “riesgología”, para mencionar un peligro mayor y casi ignorado por el gran público; del orden de los 4 millones de decesos anuales, su letalidad aumenta constantemente y es atribuible sobre todo a los modos de vida “modernos”.

En el balance de las fobias, no todas las patologías son equivalentes (y tampoco, sobre todo, las poblaciones que las padecen). ¿Por qué la gripe aviar o la gripe porcina conllevaron a una movilización de los responsables sanitarios, cuando la simple gastroenteritis (bacteriana y sobre todo viral) mata a casi un millón de niños y a 600.000 personas por año en los países pobres, sin que ello parezca preocupar a los amantes de las grandes inquietudes? Relativamente benigna en Francia, la enfermedad pasó el umbral epidémico incluso en ese país, ya que algunas formas han sido inducidas por bacterias resistentes y otras por virus que podrían mutar…

Desplegar los discursos de la ciencia y de la responsabilidad política en materia de salud en un registro del miedo, para movilizar mejor a las poblaciones contra peligros aún potenciales, comporta consecuencias negativas. Repetidos por todos los medios “pedagógicos”, terminan combinándose con un conjunto de orientaciones ansiogénicas que no resultan ajenas a la explosión de las expresiones directamente… “paranogénicas”. Quienes ganan con el miedo están presentes en ese derrotero: “¡Socorro, la gripe aviar!”, clamaba Santé Magazine el 12 de diciembre de 2008. O el fabricante de barbijos para la gripe cuyo eslogan publicitario en internet es “¡No espere a que sea demasiado tarde!”.

Ahora bien: hacer demasiado hincapié en los peligros presentados como apocalípticos refuerza la inquietud de los más manipulables (las encuestas indican que las categorías modestas tienen más miedo de la gripe A que los cuadros superiores) (12) y favorece el imaginario de lo peor: los discursos de enloquecimiento se multiplican, transmitidos sobre todo por grupos sectarios que, con la cara más o menos descubierta, acusan a los “amos del mundo” de querer enfermarnos a propósito, con el pretexto de curarnos (13). Es así como, en la página de internet, Catherine Austin Fitts (subsecretaria de Vivienda de Estados Unidos durante el primer mandato de George W. Bush) prevé con tristeza y horror que la gripe y sus vacunas serán utilizadas para disminuir la población humana que está “fuera de control” (14).

El tema de la vacunación, libre u obligatoria, fue objeto de miedos populares desde principios del siglo XIX. Aunque es innegable que la vacuna salvó o prolongó millones de vidas, también existieron los efectos “iatrógenos” (15), como ocurre con todas las técnicas de cura. Hoy, esos efectos tienden a combinarse con un rechazo cultural global de las intervenciones colectivas sobre el cuerpo humano: el implante subcutáneo de los microchips electrónicos se erige como “marca del diablo” cuando en realidad es de utilización infrecuente (y reprobada) (16). Eso no impide que pueda encontrarse en internet la combinación sistemática del rechazo a la vacuna y el microchip, en una reacción exaltada a un “gobierno mundial” satanizado, que supuestamente quiere reducir y esclavizar a la población del planeta, todo en referencia al apocalipsis bíblico (17).

En ambos casos, el núcleo de la fantasía está representado por la penetración de la piel (el antibiótico, quizá porque a menudo se lo administra por vía oral, no despierta esta reacción). Como si el descubrimiento de Pasteur de nuestra condición de especie sometida como tal a la contaminación entre todos sus miembros fuera más insoportable en la medida en que es reafirmada por la sociedad, permitiéndose perseguir los organismos patógenos “por efracción” en el cuerpo de cualquiera.

A fin de cuentas, el mayor riesgo no es siempre aquél en el que más se piensa. La deriva de nuestras sociedades hacia la obsesión securitaria puede ser uno –y de los más graves–, sobre todo porque impide toda política sanitaria razonable y concertada. Un clima de desconfianza generalizado explica en parte las dificultades de dar información franca sobre las realidades epidemiológicas y sobre las soluciones terapéuticas o las campañas de policía sanitaria. El hecho de que estas dificultades alimenten a su vez rumores absurdos forma parte del problema. De igual modo, una interpenetración creciente en las cuestiones de salud pública, las políticas sociales y económicas, e incluso los desafíos estratégicos y geopolíticos, favorece la puesta en orden autoritaria y el recurso al secreto.

Es de suma urgencia ofrecerle al público los medios para que éste establezca sus propias opiniones sobre bases serias, comprendiendo y respetando las emociones y las angustias que nunca carecen de fundamento. Pues los partidarios de que la ciencia “se abra paso a la fuerza” podrán tener razón en términos de urgencia, incluso de democracia sanitaria, pero no podrán negar el hecho de que esas fantasías tienen cierta porción de verdad. Cuanto más se comporte la sociedad humana como un recipiente único de las pandemias, ellas mismas multiplicadas, más nos enfrentaremos a una autoridad que pretenda representar a esta especie: un biopoder universal, en un sentido más preciso que el que señaló Michel Foucault (18).

He aquí, pues, una contradicción irreducible con la cual debemos vivir: aceptar nuestra realidad biológica exigiendo al mismo tiempo ser respetados como sujetos políticos y privados, como seres singulares. La necesidad de proceder a arbitrajes entre esos dos aspectos contrarios conducirá a tolerar sus consecuencias (que a veces son mortales). Así, en tanto pueblos, podemos decidir preferir cierto nivel de muertos en la ruta a la inclusión de detectores electrónicos en nuestros autos, o enfrentar valientemente tal o cual epidemia de gripe invernal antes que vernos obligados a la vacunación.

Pero sería una lástima e incluso estúpido que, como en Nigeria, debamos sufrir una reactivación fulgurante de la poliomielitis entre los niños, sólo por haber desarrollado una desconfianza paranoica respecto de los “vacunadores envenenadores” (19). Sería igualmente poco razonable esperar pasivamente que se produzca un eventual “casamiento” de los virus H5N1 y H1N1, corriendo el riesgo de ver cómo cae buena parte de nuestra población en la flor de la edad. El derecho a cuestionar la obligación de vacunación podría admitirse, en cambio, en el caso de patologías mal delimitadas, o en el de técnicas que son objeto de polémicas entre los expertos.

Finalmente, es importante señalar, acerca de la denuncia de las intenciones de manipulación de los virus con el objeto de hacerlos aun más mortales (por ejemplo, en el marco de un “bioterrorismo” privado o estatal), primero, su carácter poco realista: no es que el armado de virus patógenos sea técnicamente imposible de realizar en laboratorio (se hace todos los días, con fines terapéuticos o experimentales), sino que esas manipulaciones no tendrían muchas posibilidades de obtener la eficacia de una mutación natural.

En general, por otra parte, las diseminaciones accidentales de organismos modificados se “apagan” en contextos que casi siempre les son desfavorables. Además, para tener éxito en la fabricación de la enfermedad exactamente adecuada a los intereses de tal o cual grupo o de tal o cual Estado terrorista, primero habría que padecer fracasos de experimentos en tamaño natural, lo cual atraería la atención de todos los servicios de inteligencia del mundo. En suma, si se alimentan las intenciones más oscuras respecto de nuestra especie, más vale remitirse a la naturaleza, en un contexto de superpoblación, que abocarse a intentos azarosos.

Adjudicarles a los funcionarios nacionales o internacionales intenciones oscuras, e incluso criminales, pensando que hasta pueden llegar a preparar –en connivencia con los laboratorios farmacéuticos– un genocidio mundial con vistas a disminuir la población “excedente”, no sólo es un perfecto absurdo, sino además una incitación al odio, y hasta un llamado al linchamiento. Los médicos, investigadores y funcionarios de la salud que trabajan en el difícil ámbito de las epidemias actuales, y que pueden intervenir en procesos de policía sanitaria, son en su inmensa mayoría personas consagradas a la causa que honra a sus profesiones: proteger y salvar. Saben también que cuando el miedo irracional se apodera de la población, son los primeros en ver comprometida su seguridad.

El fantasma de una purga demográfica

Así pues, sería un error abordar las fantasías solamente como miedos que enmascaran dudas útiles, inquietudes legítimas o resentimientos admisibles. También hay que considerarlos a veces como deseos innombrables, mucho más fácilmente atribuibles al “enemigo”. Tal es el caso de la indignada denuncia, en ciertos blogs, de una supuesta intención genocida respecto de un “sobrante demográfico” (20). Hay allí no tanto un objeto de espanto como un deseo muy extendido, aunque disfrazado e hipócritamente atribuido a un mítico personaje malhechor. Admitamos por un momento, para citar a Claude Lévi-Strauss, ese sordo deseo “como el agua corrompida de una humanidad saturada de su propio número y de la complejidad cada vez mayor de los problemas, como si se le hubiera irritado la epidermis por el frotamiento que resulta de los intercambios materiales e intelectuales aumentados por la intensidad de las comunicaciones” (21). ¿Es por ello lícito imaginar que una vasta “purga demográfica”, que por fin solucionaría la interminable crisis económica, resultaría más deseable por ser naturalmente el efecto de una “buena gripe”?

Pueden “oírse” los argumentos en este sentido: en efecto, la Inglaterra democrática moderna, “madre de los Parlamentos”, nació de las condiciones sociales radicalmente mejoradas por la gran peste de 1350 (suba de los salarios de los sobrevivientes, retroceso de la servidumbre, baja de la renta hipotecaria, etcétera). Sin embargo, ese tipo de razonamiento está sujeto a caución en más de un sentido, incluso más allá del cinismo inhumano que implica: una disminución brutal de la población tendría hoy como efecto inmediato el considerable agravamiento de la crisis económica en curso, la caída de la producción, los empleos y sus ingresos, la imposición de regímenes drásticos. De modo que puede parecer absurdo imputar ese fin a los “horrendos capitalistas” cuyo objetivo es, por el contrario, alimentarse de todo tipo de crecimiento y aspirar a una “reactivación” cada vez mayor.

Pero el apetito por la enfermedad mortal “salvadora” nunca se presenta francamente como lo que es: parece rechazarse con un santo horror a la imagen caricaturizada de la elite internacional o los “Illuminati”, esos nuevos monstruos y asesinos seriales imaginarios de la historia globalizada. Así fue como la periodista austríaca Jane Burgermeister presentó una denuncia en la oficina del Fiscal de Viena, el 8 de abril de 2009, contra las empresas Baxter AG, Baxter International y Avir Green Hill Biotechnology AG “por haber desarrollado, manufacturado, diseminado y extendido un arma biológica de destrucción masiva en suelo austríaco entre diciembre de 2008 y febrero de 2009, con la intención de provocar una pandemia mundial de gripe aviar, y con el objetivo de extraer ganancias de esta pandemia, violando las leyes sobre el crimen organizado y el genocidio”. A continuación, Burgermeister declara haber perseguido a una cantidad de responsables internacionales y dirigentes políticos, pero también a los “Illuminati” y al Grupo de Bilderberg (22), “por consentir, a sabiendas, una campaña de vacunación que en realidad permitía inocular a la gente una ‘mezcla’ de virus aviares y porcinos, con el fin de matar a un gran número de personas” (23).

La propagación de los rumores más infundados y más locos que acusan a la OMS, Barack Obama, David Rockefeller o George Soros, todos mezclados –acelerada y extendida por internet–, moviliza el deseo mortífero que hoy en día atormenta a todos los sujetos de esta sociedad mundial opresiva y peligrosa, incierta y desorientada. A su vez, reanuda fenómenos de agitación demográfica (que a veces se vinculan con las epidemias de las que antes se acusaba a los extranjeros o a los judíos) y renueva, en la escala de internet, la capacidad embotada de los medios de comunicación tradicionales para precipitar la opinión pública hacia el entusiasmo o la desconfianza.

Como recuerda Pascal Froissart a propósito de las teorías conspirativas (24), “el derecho a la duda” es importante e incluso “sano”; pero cuando se transforma en la obligación de un ser aterrorizado, entonces entramos en otra lógica: la de los períodos oscuros de la historia.

1 Parecida a la enfermedad de Creutzfeld-Jacob.

2 En Francia, “el caso de la sangre contaminada” reveló que, en 1984-1985, las instituciones de transfusión de sangre habían distribuido a hemofílicos productos contaminados por el HIV, cuando ya se sabía cómo eliminar el virus. En 1999, Laurent Fabius (entonces primer Ministro) y Georgina Dufoix (ministra de Asuntos Sociales) fueron declarados inocentes de la acusación de “homicidio involuntario”. Otros casos de contaminación masiva tuvieron lugar en otros países, en particular en China.

3 Presidente de Médicos Sin Fronteras de Francia entre 1982 y 1994. Véase Rony Brauman, “Mission civilisatrice, ingérence humanitaire”, Le Monde diplomatique, París, septiembre de 2005.

4 Discurso de Jacques Diouf, director de la Organización de las Naciones Unidas para la Alimentación y la Agricultura (FAO), en la Cumbre Mundial de la Alimentación, 3-6-08.

5 Entrevista a Patrick Zylberman, “Grippe: 2009 n’est pas 1918”, Le Monde, París, 9-5-08.

6 Fuentes: National Nosocomial Infections Surveillance System (NNIS; un departamento de los Centers for Disease Control, Atlanta); Informe de la Oficina Parlamentaria de Evaluación de Políticas de Salud (OPEPS), París, 2006; Informe Raisin (red de alerta, investigación y vigilancia de las infecciones nosocomiales), Saint Maurice, 2006.

7 Así, aparecen resistencias al Tamiflu, un medicamento que limita eficazmente la diseminación del virus gripal. Por otra parte, un estudio holandés sobre 1.500 personas infectadas por el HIV mostró en 2003 que aparecían resistencias a cada clase de tratamiento, antes incluso de su aplicación: las personas eran portadoras de cepas ya resistentes.

8 Respectivamente: colaborador de la OMS sobre contacto animal/humano de las gripes (Webster); virólogo de la universidad de Wisconsin (Kawaoka); director del instituto Erasmus, de Rotterdam, que en 1997 demostró que el H5N1 podía transmitirse al hombre (Osterhaus); creador, en Francia, de los Grupos Regionales de Observación de la Gripe (GROG), ampliamente imitados en otros países (Hannoun); biólogo de la universidad de Hong-Kong (O’Toole).

9 Cualquier acción que previniera la aparición de una patología. Por ejemplo, el hecho de lavarse las manos adecuadamente pudo reducir en un 50% las infecciones contraídas en los hospitales.

10 Según el epidemiólogo Antoine Flahart, Libération, París, 7-12-05.

11 Le Monde, París, 6-8-09.

12 Encuesta IFOP-Dimanche Ouest France (citada en L’Express, París, 1-8-09).

13 Un tema agitado sobre todo por el sitio Spread the Truth (véase: y ampliamente transmitido.

14 Pero también afirma que una economía mundial estabilizada implica la reducción de la población humana a 500 millones de habitantes.

15 Patología generada por la actividad médica (iatros: “médico” en griego).

16 Según sus promotores, el microchip implantado bajo la piel podría ser útil, en caso de internación, para identificar a la persona, disponer de su historia clínica, determinar sus alergias, los medicamentos que toma, etc. Inútil decir que esa fantasía “utilitaria” es el espejo a quien esto espanta tanto como para perder cualquier confianza en la sensatez de la gente.

17 Ver los sitios:;;;;;; (para no hablar de la constelación de “tags” (etiquetas) que vinculan estos temas con la “conspiración del 11 de septiembre”, el cuestionamiento de dirigentes “criminales”, la acusación de Israel, etcétera).

18 La voluntad de saber, Siglo XXI Editores, México, 1977.

19 La teoría de la transmisión del HIV al hombre durante la preparación de vacunas de la poliomielitis en el Congo es objeto de una controversia no cerrada entre el periodista británico Edward Hooper y la mayoría de los especialistas.

20; Spread the Truth; Eva R-Sistons, Solari, etc.

21 Claude Lévi-Strauss, Tristes trópicos, Eudeba, Buenos Aires, 1970.

22 Red de influencia, el Grupo de Bilderberg reúne a personalidades de todos los países –dirigentes de la política, la economía, las finanzas, los medios, jefes del ejército o de los servicios de inteligencia–, así como a algunos científicos y universitarios.

23 Rumor propagado sobre todo por Barbara Minton, “Journalist Files Charges against WHO and UN for Bioterrorism and Intent to Commit Mass Murder”,, 25-6-09.

24 Docente investigador en la universidad de París VIII, autor de La rumeur. Histoire et fantasmes, Belin, París, 2002.