Policy Studies

ISSN: 0144-2872 (Print) 1470-1006 (Online) Journal homepage: http://www.tandfonline.com/loi/cpos20

Because we all know that vaccines are an

extremely effective public health tool: path
dependency, H1N1 and the World Health
Organisation
Sudeepa Abeysinghe
To cite this article: Sudeepa Abeysinghe (2012) Because we all know that vaccines are
an extremely effective public health tool: path dependency, H1N1 and the World Health
Organisation, Policy Studies, 33:5, 381-397, DOI: 10.1080/01442872.2012.719725
To link to this article: http://dx.doi.org/10.1080/01442872.2012.719725

Published online: 31 Aug 2012.

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Policy Studies
Vol. 33, No. 5, September 2012, 381
397

RESEARCH ARTICLE
Because we all know that vaccines are an extremely effective public
health tool: path dependency, H1N1 and the World Health Organisation
Sudeepa Abeysinghe*
School of Sociology, Australian National University, Acton, ACT 0200, Australia

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(Received 22 December 2011; final version received 4 July 2012)

Infectious disease threats are surrounded by scientific uncertainty. As a result,
institutional structures can heavily determine the way in which such risks
are managed. This is illustrated by the World Health Organisations (WHO)
management of the 2009 H1N1 pandemic. Given this, theories of path
dependency, derived from the new institutionalism, are useful in analysing
such events. This article examines theories of institutional and discursive path
dependency in respect to the case study of the WHOs management of H1N1.
It argues that the WHOs emphasis on the use of vaccines as a protective measure
constitutes a path dependent reaction, based on the organisations historical
achievements with vaccines and its discourse surrounding vaccine use. Furthermore, in contrast to accounts which understand historical and institutional path
dependency as exclusive theoretical models, the article argues that institutional and discursive path dependencies were mutually interacting in forming
the WHOs response to H1N1. Finally, the article explores the question of
institutional change within theories of path dependency. Here, using the case
of the WHO, it is shown that the interference of an outside actor, the Council
of Europe, caused the WHO to internally evaluate its actions, leading to
institutional change.
Keywords: path dependency; pandemic; H1N1; sociology; World Health
Organisation

Introduction
The 2009 H1N1 pandemic was an important event in the recent history of infectious
disease, as the declaration of the pandemic precipitated the mobilisation of global
management plans. The World Health Organisations (WHO) response to H1N1
was pivotal to the pandemics management, as the WHO was the organisation
responsible for both declaring the pandemic and co-ordinating worldwide reactions
to it. This article examines the WHOs reaction to the 2009 H1N1 pandemic.
The article bases its arguments on the analysis of key documents produced by the
WHO and the Council of Europe. This documentary evidence demonstrates that the
WHO emphasised the use of vaccine as a management strategy against the H1N1
virus. This focus on vaccines mirrored the WHOs experience with mass vaccination
campaigns, including a resonance with major organisational achievements, such as
the eradication of smallpox, and it is institutionalised discourse surrounding vaccine
use. The WHOs use of vaccines, therefore, reflected a well-worn institutional process
*Email: sudeepa.abeysinghe@anu.edu.au
ISSN 0144-2872 print/ISSN 1470-1006 online
# 2012 Taylor & Francis
http://dx.doi.org/10.1080/01442872.2012.719725
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382 S. Abeysinghe
in disease management. In this way, in reacting to the H1N1 pandemic, the WHO
acted in a path dependent manner.
Through an analysis based on the concepts of discursive and institutional path
dependency, the article demonstrates not only the WHOs path dependent reaction,
but also that these two forms of path dependency are not necessarily distinct, as prior
literature suggests. Rather, discursive frameworks interact with institutionallyembedded processes in producing policy responses. The case study of the WHOs
management of H1N1 is particularly valuable in analysing these concepts, since
the H1N1 pandemic represented a disruption to the path dependent processes of the
WHO. The failure of H1N1 to produce severe global disease, in respect to morbidity
and mortality rates, combined with the WHOs strong reaction against the event,
resulted in widespread contestation and critique of the path dependent institutional
response, and further opened the WHOs processes up to analysis.
The article first outlines the theory of path dependency, the debates between
authors who emphasise institutional and discursive path dependencies, and the
criticism that these concepts inadequately explain policy and institutional change.
It then utilises documentary evidence to examine the WHOs management of H1N1,
showing that there were interacting discursive and institutional elements to the
WHOs response. Consequently, it argues that treating institutional and discursive
path dependency as alternative explanatory concepts is misguided, as they interact
with each other in producing an institutional reaction. Finally, the article examines
the critique of the WHOs response made by the Council of Europe. This underpins
the argument that institutional change can be occur where the critique of outside
actors forces an organisation to examine its processes, demonstrating that theories of
path dependency do not necessarily preclude an understanding of institutional or
policy change.
Understanding institutional stability or change
Theoretical interest in institutions within political and economic sociology revived
with the rise of new institutionalism in the 1980s (Lowndes 2002, 2010). In contrast
to the predominantly structural-functionalist and behaviourist tendencies of traditional institutionalism, the new institutionalism is populated by a diverse array of
theoretical accounts. Within these, the notion of path dependency is one of the most
useful and well-theorised concepts in explaining institutional responses. As with the
new institutionalism in general, the concept of path dependency has been applied
diversely within different theoretical paradigms (Hall and Taylor 1996, Hay and
Wincott 1998, Blyth 2003, Schmidt 2010). A multitude of distinctions between
different forms of path dependency have been developed through diverse theoretical
approaches to the study of institutions. However, the major distinction invoked in the
literature is between discursive and institutional path dependency.
Discursive path dependency, arising from the broadly constructivist approach of
discursive institutionalism, maintains that discourses produced by an institutions, or
between institutional actors, frame actions (Schmidt 2008). The approach investigates the way in which core institutional narratives impact upon decision-making
processes. A discursive path dependency approach suggests that institutional
discourses construct and frame responses and procedures. Here, it is the discourse
that creates actions, through the reinforcement and justification of the roles and

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Policy Studies 383

goals of an organisation. Furthermore, this approach also emphasises decisionmaking as an outcome of the discursive processes underlying it
the institutional
actions vary according to the way in which the discourse surrounding a problem is
constructed (Blyth 2007, Schmidt 2010).
In contrast, institutional path dependency, emphasised by historical institutionalism, suggests that the current and future actions of organisations are likely to be
influenced by historically-contingent decisions and processes (David 1994, Mahoney
2000). The argument here is that institutional processes are, in large part, determined
by expectations at the time of an organisations creation. While these processes can
change over time, the repeated use of a particular procedural code is self-reinforcing,
so that the organisation tends to reproduce past actions (Mahoney 2000, Greenwald
2008). The organisational structure becomes locked into a set of routines and
actions, where present action is dependent upon past procedural pathways, despite
the fact that the initial rationale and roles of the organisations may have become
irrelevant over the course of time.
These two forms of path dependency have been understood as alternative
explanations of organisational action, stemming from competing ontological
positions (Hay and Wincott 1998). However, many argue that both of these forms
of path dependency have difficulty in explaining organisational and policy change;
they tend to understand organisations as both stable and unchanging (Blyth 2003).
Discursive institutional constructs tend to self-reinforce and persist over time.
Similarly, organisational processes are also seen as remaining stable. Within theories
of path dependency, even where change occurs, it is understood that organisations
typically evolve slowly over time, in a way which is shaped by preceding functions
and objectives or discursive framings (David 1994, Campbell 2010). In this way, it
has been suggested that, although there is a renewed interest in institutions, the
question of institutional origin and institutional change, remains somewhat underanalysed (Pierson 2000).
The dominant approach to articulating institutional change tends to utilise a
basic functionalist reasoning, suggesting that institutions originate and subsequently
change as a response to varying needs (Lowndes 2010), or that institutions change
endogenously through cumulative effects or minor shifts (Djelic 2010, Mahoney and
Thelen 2010). In contrast, the potential for exogenous shocks to rupture and
restructure institutionalised positions presents an alternate explanation (Djelic 2010,
Hall, 2010). Alternatively, change is understood as the result of the mobilisation of
power groups, either upon or within the institution, or the function of internal agents
constructing new discourses that result in change (Hall and Taylor 1996, Schmidt
2010). However, on the whole, stability is emphasised. This article argues that
institutional and discursive path dependencies can in fact be useful models through
which to view institutional change, particularly under certain circumstances.
Specifically, the case study of the WHOs response to H1N1 demonstrates that
path dependent reactions can be challenged and modified through the engagement of
extra-institutional actors, who can precipitate an internal evaluation of processes.
Exogenous shocks motivate endogenous reactions, which are in part formed by
existing processes.
Overall, although discursive and institutional path dependencies attempt to
explain the same phenomenon
how institutions (re)produce their actions
they are
generally understood as competing perspectives (Hay and Wincott 1998). On the face

384 S. Abeysinghe

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of it, the contrast between an argument centred upon the reinforcing tendency of
institutional process and one based upon a constructionist account of the effect of
discourse appears significant. However, while the theoretical influences behind these
perspectives differ to some extent (in that a strongly constructionist account does not
allow a realist focus upon reinforcing historical forces), in practice both discourse
and historically-reinforced institutional structures interpenetrate in framing an
organisations response. As such, the key argument here is that institutional and
discursive path dependencies are not mutually exclusive; rather, they tend to reinforce
each other. The case study of the WHOs management of H1N1 demonstrates this
interaction and suggests that the divergent theoretical approaches to path
dependency are not incompatible. Rather, the WHOs contemporary responses can
be best understood as a result of both the institutional and discursive path
dependency of the organisation.

Case study
The H1N1 pandemic and the WHOs role in its management
The 2009/10 H1N1 pandemic presents a useful opportunity to apply and examine
concepts of path dependency. The WHO plays an important co-ordinating role
within the current model of global public health (Fidler 2001, Ollila 2005, Brown
et al. 2006). Given the recent interest in influenza pandemics (Lee 2003, Woodward
and Smith 2003, Lee 2005, Taylor 2005), one of the most prominent contemporary
functions of the WHO is to manage pandemic events. Potentially, a severe worldwide
influenza pandemic could cause widespread social and economic disruption. The
threat of such events, therefore, gives rise to a range of public and institutional
reactions (von Schomberg 1993, Jasanoff 2004a, 2004b), with the WHO responsible
for managing and co-ordinating the actions of national governments and other
stakeholders (such as pharmaceutical corporations and NGOs).
Recently, there have been a number of pandemic scares, including SARS (2003)
and avian influenza (2004
06). The most recent, and largest, alert surrounded the
2009 A(H1N1) strain of influenza which, from its first reporting in Mexico in March
2009, raised fears of a pandemic. On 11 June 2009, following the global spread of the
virus, the WHO officially declared H1N1 to constitute a Phase 6 Pandemic
the first
pandemic declaration in 40 years (Cohen and Enserink 2009). This declaration
resulted in the enactment of national pandemic preparedness plans and global
actions to combat the threat. Foremost amongst these, as the article emphasises, was
the global production and distribution of vaccines against the H1N1 influenza strain.
However, subsequently the actions of the WHO have been called into question.
Despite the early fears surrounding H1N1, the virus failed to become a severe global
threat. This left the responses of the WHO open to contestation. Specifically,
organisations such as the Council of Europe, who were subject to the WHOs
management decisions, heavily criticised the WHOs reliance on the use of vaccines in
reaction to H1N1. As demonstrated later, the Council of Europe asserted the
vaccines were neither the most appropriate, nor a justified, reaction. As such, the
WHOs reaction to H1N1 came under intense media and public scrutiny.
The Council of Europes argument centred upon the assertion that the WHOs
actions reflected the economic interests of pharmaceutical industries. Indeed, it has

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been argued that networks of NGOs, nation states and corporations engage in profitmaking interventions in multiple areas of global public health (Silverman 1976,
Elling 1981, Vance and Millington 1986, King 2002). This Marxist political economy
approach suggests both that such interventions are the outcome of a global capitalist
structure and also that these networks serve to manufacture not only drugs, but also
diseases (Moynihan 2002, Moynihan et al. 2002, Williams et al. 2008). However, the
WHO would not have benefited from a false scare, since this would, in fact, have
served to undermine its long-term credibility. Furthermore, the specific emphasis on
vaccines hardly fits a Marxist explanation, given that measures such as anti-virals
would be equally profitable. A path dependency analysis more convincingly explains
the WHOs favour of vaccines, as this article demonstrates.

The interaction between institutional and discursive path dependencies in the WHOs
reaction to H1N1
The utility and efficacy of vaccines
Due to the inherent scientific uncertainty surrounding the circumstance (as a
potential and future-orientated risk), the case of H1N1, as with the management of
many contemporary risks (Funtowicz and Ravetz 1994, Shackley and Wynne 1996,
Lynch 2004, Nowotny 2003), necessarily meant that the WHO needed to choose
from amongst a plurality of potential reactions. This is because, where there are
conditions of technical and scientific uncertainty, a risk tends to be ill-characterised
and consequently open to (multiple) interpretation. In such cases, there is a tendency
for policy-makers to simplify and perceive problems in ways that minimise the types
of potential solutions, in order to render the risk manageable (Janes and Corbett
2009). Given this climate of uncertainty, institutional structures can significantly
shape the course of action. In the present case, the WHOs reliance on vaccines as a
containment strategy demonstrates the critical role institutional forces played in
framing the organisations response to the pandemic.
The WHOs response to the H1N1 pandemic was clearly path dependent. This is
not to say that the response was inappropriate or unjustified (in fact, the article
makes no claims about the validity, or otherwise, of the WHOs actions), but rather
to argue that the organisation followed an institutionally predictable direction in its
actions. This is evident through an examination of both WHO documents and the
wider history of the organisation. The WHOs narrative surrounding the utility and
efficacy of vaccines amply illustrates this point. The utility of vaccines was presented
as unproblematic within the WHO narrative. It was taken for granted that vaccines
would provide the most effective control measure. Vaccines were emphasised as the
best (and only real) strategy. This view ran contrary to contemporary research which
suggests that other health measures (particularly social distancing and prophylactic
anti-viral use) are likely to have greater efficacy than vaccination in significantly
affecting the impact of a pandemic (e.g. Ferguson et al. 2005, Ferguson et al. 2006).
It was also in contradiction to the narratives of other public health actors, who
expressed concern over the WHOs emphasis on vaccines (see the Council of Europe
response later).
Historically, the WHO has turned to mass immunisation campaigns as a reaction
to global public health disasters. It is, therefore, unsurprising that immunisation was

386 S. Abeysinghe
forwarded as an effective strategy against H1N1, given the scientific uncertainty
surrounding the risk. The use of vaccines was promoted by the WHO as an effective
tool to combat H1N1. It was asserted by Keiji Fukuda, the WHO Assistant General
and Special Advisor on Pandemic Influenza, that all countries will need access to
vaccines (Fukuda, 24/9/09) to deal effectively with H1N1. From the initial discovery
of the viral spread, vaccinations were focused upon as a justified reaction. As the
WHO put it:

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Why are we so interested in vaccines against this new virus? It is because we all know
that vaccines are an extremely effective public health tool and in addition, vaccines
against seasonal influenza are protective against the disease
in severe disease
of
millions of people every year. So, therefore, it is generally recognized and accepted
that it would be critically important to have a vaccine if you want to stop the
pandemic that might be coming with this virus. (Fukuda, 01/05/09)

Vaccinations were, therefore, strongly advocated as the most effective method of

minimising the risk of H1N1 in the WHOs perspective.
The WHO provided evidence for this support of vaccines in a number of ways.
Importantly, historical events were referenced as evidence of the effectiveness of
vaccination against infectious disease. It was asserted by the WHO representatives
that:
It is clear when you look at the Twentieth Century that vaccines have been one of the
most effective and most cost-effective and safest ways to protect people against a
wide range of infectious diseases. Again, these include diseases such as yellow fever,
polio, measles, meningitis, small pox, and so on. There is a list which goes on and on,
but the idea is basically the same. It was true and is also true for pandemic influenza.
(Fukuda, 03/12/09)

This quote demonstrates both discursive and institutional path dependencies of the
WHO in managing the H1N1 pandemic. Historically, the organisation had relied
upon vaccines as a protective measure. However, the utility of vaccines is also
strongly discursively presented, such that the discursive and historical path
dependencies combine in the WHOs perspective upon H1N1.
This unquestioned dependence on vaccines can be understood as a result of the
organisations historical successes with vaccination campaigns. Since its founding,
the management of infectious disease has been considered by the WHO as its
primary function. In its early development and actions, the WHO focused on
infectious diseases such as malaria, tuberculosis and venereal disease, and was only
secondarily concerned with basic health services (Beigbeder 1998). Over time, this
focus upon infectious disease remained (Corrigan 1979, Beigbeder 1998, Fee et al.
2008). Although the WHO began to emphasise horizontal health programmes
(programmes which aim to minimise all disease within a region, such as integrated
public health programmes and sanitation), vertical disease campaigns (which focus
on one targeted disease) have been historically emphasised.
These vertical health programmes have tended to be campaigns against infectious
disease. Beigbeder (1998, p. 126) argues that for the organisation:
[i]n contrast with the sometimes vague objectives of some of the WHOs
programmes, the advantage of a vertical programme is to have identified a specific

Policy Studies 387

enemy, to know the technical means to control or eradicate it (immunization,
effective medicaments etc.) and to be able to measure or evaluate the result of the
campaign.

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Campaigns against infectious disease have thus characterised the WHOs overall
function and marked the key successes (and failures) of the organisation. Indeed, the
problem of H1N1 was discursively framed through comparison with past disease
events:
Many of you know that the world has been talking about and preparing for
pandemic influenza for at least the past five years and there are a number of reasons
for this. We know that influenza pandemics have occurred at least a couple of times
each century and in the last five years we have been working very hard . . . because of
a specific pandemic threat known as avian influenza or H5N1 and because of that
many countries have been very focused on strengthening their defences for such a
situation. (Fukuda, 26/04/09)

Here, we see the discourse depicting a historical battle with global disease threats,
including more recent pandemic threats, which frames the institutional processes and
orientation of the WHO. Infectious disease campaigns are key to the WHOs
discursive framing of its roles and goals within global health. The WHOs successes
revolved around infectious disease and this is mirrored by both its discourse and its
(historically-bound) institutional processes.
In particular, the WHOs campaign against smallpox serves as a prototypical
example of the organisations success in controlling infectious disease, and it is
perceived and discursively related by the organisation itself as a critical historical
juncture (WHO 2007, Fee et al. 2008). The mass immunisation campaign waged
against smallpox provided a perspective through which the organisation has
managed subsequent cases. Importantly, following this early success, vaccination
became the WHOs dominant strategy in controlling infectious disease. These
vertical campaigns against infectious disease have become prominent in the WHOs
history and were highlighted given that the success of such campaigns: enhances
durably and visibly the Organizations prestige (Beigbeder 1998, p. 126). In fact, even
the prominent failures of these campaigns lies in part in the WHOs dependency on
vaccination as a resource against communicable disease. Most notably, the failure in
malaria eradication was underpinned by the emphasis on finding a vaccine, rather
than relying upon other possible options (Turnbull 1989, Beigbeder 1998). This
reliance was despite the fact that, to date, there have been no effective vaccines
produced against human parasitic infection (Abath et al. 1998, Beverley 2002,
Dadara and Harn 2005).1
As a consequence of this institutional and discursive framing, vaccines were
presented as the logical action against H1N1. The use of vaccines was unquestioned
and, where the WHOs perspective was challenged, the organisations spokespeople
simply reiterated the discourse of vaccine utility:
One of the most basic questions to ask about vaccines is why are these being
promoted? Why are these useful? I think here the answer is relatively straightforward
and simple. We are in a situation in which the world is seeing a new infection, this
pandemic influenza. This is an infection which clearly can cause death or serious

388 S. Abeysinghe
illness in a number of people . . . We now have vaccines which are developed
specifically against this infectious disease. (Fukuda, 05/11/09)

This understanding was also clearly embedded within a historically-framed institutional discourse:

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It is clear when you look at the Twentieth Century that vaccines have been one of the
most effective and most cost-effective and safest ways to protect people against a
wide range of infectious diseases. Again, these include diseases such as yellow fever,
polio, measles, meningitis, small pox, and so on. There is a list which goes on and on,
but the idea is basically the same. It was true and is also true for pandemic influenza.
(Fukuda, 03/12/09)

Here, the use of vaccines themselves is taken for granted by the WHO as the justified
method for managing H1N1. This mirrored the pre-existing narrative of vaccines
and the institutional procedure for reacting to pandemic threat evident within the
organisations actions.

The safety of vaccination

The safety of the vaccines was questioned by outside actors (see later), but the WHO
narrative continually reinforced its institutional position on vaccines, suggesting that
mass vaccination had been historically useful and that its own regulatory
mechanisms safeguarded the H1N1 vaccines.
In this way, institutional processes again shaped the discourse surrounding
preparations
here with the suggestion that effective regulation produced a safe and
justified response. The WHO argued that risk was minimal because of the effective
regulatory practises the organisation adopted (Levidow 2001, Saloranta 2001, Ravetz
2004, Rothstein 2006, Rothstein et al. 2006, Marshall and Picou 2008), focusing
upon the regulation of risk. As such, the WHO argued:
What we would like to avoid is to say, we dont know whether it will be safe or not be
safe, so lets gamble on safety. I dont think WHO nor any regulatory authority wants
to gamble on this. You may remember that there were some difficulties in 1976 with
the last scale mass vaccination campaign in the US against an outbreak of swine flu
and nobody would like to repeat this experiment. (Fukuda, 06/05/09)

Here, the emphasis on vaccines, as elsewhere in WHO accounts, centred around the
procedural aspects of vaccine developments and the WHOs own regulatory
mechanisms for safety control.
The WHO also referred to prior use of vaccines as demonstrating the safety of
this intervention, promoting the vaccines by emphasising their proven use and
efficacy. Thus, Fukuda, the WHO Assistant Director-General, stated that: I would
also like to point out that part of the vaccines are based upon very old and proven
technology which are used for seasonal vaccination. He continued, emphasising
that: [n]o new safety issues have been identified from reports received to
date . . . reporting so far reconfirms that the pandemic flu vaccine is as safe as
seasonal flu vaccines (Fukuda in Kieny, 19/11/09). This comparison with seasonal
influenza vaccines served to assure safety, because: for seasonal vaccines, millions
upon millions of doses have been administered to all kinds of populations . . . (Kieny,

Policy Studies 389

06/08/09). As such, Fukuda (03/12/09) asserted: . . . so far we have not seen any
unexpected safety issues emerge, and the safety profile continues to be similar to
what we see in seasonal vaccines. The use of vaccines against H1N1, in mirroring the
past use of similar vaccines against seasonal influenza, was reinforced both
discursively and procedurally.

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Other preparatory actions

The argument that the WHO acted in a path dependent manner when responding to
H1N1 through the use of vaccines can be further evidenced by an analysis of the
organisations discourse surrounding other potential actions and reactions. Where
such actions, including the use of anti-viral medications, border restriction and
quarantine, social distancing, and surveillance, were acknowledged by the WHO, it
was made clear that these were secondary measures. Anti-virals and border control/
quarantine, the two most discussed alternative methods, will be looked at briefly
here. These measures were rarely addressed in the WHO documents in relation to
H1N1 and, even then, were referred to in such a way as to highlight the central role
of vaccines.
From the initial development of the perception of a threat, it was clear that
vaccines constituted the predominant reaction to H1N1. Thus, while anti-virals are
often the focus of public health campaigns against influenza-like illness, in the case of
H1N1 they were not considered at any stage throughout the threat. This was clearly
illustrated in the suggestion that:
We do not really have a very strong position on the use of anti-virals. It is part of the
National Pandemic Preparedness Plan and, of course, we do not have any experience
with treatment and clinical efficacy against this new virus. (Shindo, 12/05/09)

This quote strongly reinforces the argument that the WHO disregarded other
strategies at an early stage in events. Here, anti-virals were disregarded because of a
lack of institutional experience with their use. For this reason, the WHO was
ambivalent, at best, about the potential role of vaccines.
The WHOs narrative surrounding anti-virals was vague because the institutional
focus was, and had historically been, upon vaccines. Although anti-viral medicines
were referred to as an important strategy in pandemic preparedness plans (including
the WHOs own), which contain the official description of how pandemics should
best be managed (WHO 2009), in practice the focus on vaccines obscured any
interest in anti-virals. This evident lack of familiarity with anti-virals was articulated
as the pandemic progressed:
In the initial guidance, we took a more conservative approach because we had almost
no experience with regard to the effectiveness of the antiviral medicine in this disease,
and also we were aware that access to the influenza medicine was very limited. Now,
we have gained knowledge in effectiveness, safety of the medicine and we have also
contributed to the global availability of the medicine. (Shindo, 12/11/09)

This quote makes it evident that the WHO was not concerned with the use of antivirals through the early stages of the pandemic. Due to the institutionalised tendency
to rely upon vaccines, anti-virals were an unfamiliar and neglected potential strategy.

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390 S. Abeysinghe
It was only through the pressure of outside actors that the WHO became more aware
of the potential of anti-virals.
Thus, in contrast to the (path dependent) emphasis on vaccines, the WHO did
not have a clear position on the use of anti-virals. The same can be said for border
control and quarantine measures. Here, it is apparent that the WHO saw national
governments as responsible for applying these measures, rather than themselves
taking a strong position on these actions. Indeed, the WHO spokespeople refrained
from commenting directly upon the actions of individual countries. This is partly a
consequence of the organisations perceived role as a non-directive coordinator
(Baker and Fidler 2006, Mack 2006/7), but also, importantly, because the WHOs
position on these measures was unclear (after all, the position on vaccine use was
highly directive and positive). Thus, while it was suggested that . . . quarantine is a
long established principle . . . (Ben Embarek, 03/05/09), the WHO discourse
surrounding such measures also stated:
I do not want to comment on the specific disease control actions of different
countries. I do want to point out that quarantine, in specific situations, can be
applied and it is a quite reasonable action to take in specific situations. There
are different times when it would be reasonable and other times when it would not
be reasonable. . . . [T]here are considerations of when to apply quarantine, [and/or]
when to apply isolations as considerations. But as we have mentioned over and over
again, the situations differ and countries approaches to disease control measures
are choices. There is no set recipe of how you approach disease control and so this
will differ to some extent from country to country. So I will leave it at that.
(Ben Embarek, 03/05/09)

This quote emphasises the WHOs ambiguity surrounding isolation, quarantine and
border control. However, the key point was that, in any case, the WHO discourse
positioned national governments as ultimately responsible for these measures:
In terms of airport measures, disease control actions by different countries reflect the
decisions based on considerations in that country. Over the past few weeks, I have
not specifically said that I think that countries should do this or that or have not
commented on the disease control actions taken by countries, but I have pointed out
that there are a number of different actions that countries can take, and so leave it at
that, but these are really country level choices. (Fukuda, 11/05/09)

As such, care was taken not directly to engage with commentary upon the actions of
specific countries. More importantly, unlike the definitive position on the use of
vaccines, border control and quarantine were not heavily reinforced in the WHOs
approach.
It is clear that the WHO emphasised the use of vaccines against the H1N1
pandemic in a path dependent manner, while their position on other measures was
ambiguous at best. It has also been argued that, in the case of the WHOs
management of H1N1, both institutional and discursive path dependencies are
evident. The WHO emphasised vaccines because of the previous success of its mass
vaccination campaigns. Moreover, the organisations understanding of its role and
goals was also underpinned by a discursive framework which itself characterised
vaccines as a justified solution. Both historical institutional and discursive elements
interacted to shape the WHOs contemporary response to H1N1.

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Path dependency and institutional change: the Council of Europe

Using the case study of H1N1, it is evident that the WHO acted in a path dependent
manner and emphasised vaccines, rather than potential alternatives, as a justified
response. This suggests, as do most accounts of path dependency, that organisations
are unlikely to change either quickly or fundamentally; theories of path dependency
generally regard institutions as stable entities (Pierson 2000, Blyth 2003). However,
understanding the response of an organisation through the perspective of path
dependency does not rule out an understanding of institutional change. This is
evident in the case of the WHOs management of H1N1. Here, it is seen that, while the
WHO acted in a path dependent manner, its actions were, in fact, subject to revision
and internal evaluation due to the influence of outside actors. The fact that large-scale
organisations, such as the WHO, tend to act in a path dependent manner suggests
that radical change is unlikely to come from within the organisation itself, as path
dependency is self-reinforcing. However, outside actors can have a large influence on
the actions of an organisation, in ways that can lead to internal modifications. This is
especially, when the management decisions in question have a large-scale effect and/or
are particularly politically salient, such as occurred in the case of H1N1, where
multiple global actors had a stake in the outcome. In this case, the claims of critics,
mobilised into popular movements, served to problematise the WHOs reactions to
H1N1. One of the first and most prominent critics was the Council of Europe.
The Council of Europe challenged multiple aspects of the WHOs management of
H1N1. However, its central concern was the WHOs emphasis on the use of vaccines.
H1N1 came under investigation by the Council of Europe because it was a: pandemic
whose announcement cost the worlds tax payers hundreds of millions of Euros and at
the same time ensured enormous additional profit for producers of vaccines for the
pandemic (Kopacz [Polish Health Minister], 29/03/10). As this quote suggests, the
Council of Europe critics emphasised the potential profit motive behind the WHOs
adherence to mass vaccination. This assertion will not be discussed in depth here,
except to reinforce the earlier point that collusion with pharmaceutical manufacturers
would not be a sufficient explanation for the WHOs emphasis on vaccines, since
other measures are equally profitable. Furthermore, as the evidence provided earlier
illustrates, it is crucial that the discourse of mass vaccination is heavily embedded in
the WHOs conception of its role, thus suggesting path dependency.
What is important in the context of this article is that the Council of Europes
intervention served to problematise the WHOs actions and created the potential for
change. The Council of Europe suggested that the WHOs use of mass vaccination
campaigns was erroneous. They argued that the H1N1 virus did not necessitate such
as reaction:
[The pandemic] declaration kicked off an immediate international agenda setting
in process [including] extensive vaccination campaigns in many countries notwithstanding evidence that the influenza overall presented relatively mild clinical
symptoms. In autumn 2009, several independent medical experts raised warnings
regarding excessive vaccination activities for which, according to them, there was no
clinical scientific evidence to justify this. (Flynn 2010)

As this quote demonstrates, the critics in the Council of Europe asserted that the
WHOs actions were unjustified and concerning:

392 S. Abeysinghe

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In June 2009, the WHO declared a level 6 pandemic and vaccines were purchased in
massive quantities. Without sufficient justification, 100 000 children were vaccinated.
The way the pandemic has been handled
not only by the WHO, but by the
competent health authorities at European Union level
gives cause for alarm.
(Circene [rep for Latvia] in Council of Europe Parliamentary Assembly, 24/06/10)

Such statements made it clear that the Council of Europe regarded the WHOs
implementation of a mass vaccination campaign against H1N1 as unnecessary. This
contrasted with the WHOs account and, when reinforced by the public debate which
followed it, caused the WHO more closely to evaluate its reaction to H1N1.
The Council of Europe not only suggested that the use of H1N1 vaccines was
unnecessary, they also argued that such measures lacked efficacy (again, in contrast
to the WHOs claims). To emphasise this, the critics made comparisons between
different rates of implementation across their Member States:
Preliminary results show that there is no correlation between the amounts spent on
taking precautions and the results. The country that spent the least was Poland,
which rejected the idea that this disease was dangerous and which had suspicions
about the safety of the vaccine . . . Britain spent 570 million on medicines that will
never be used. The outcome, however, was that the number of deaths per million
from swine flu in Britain was about twice the number in Poland. (Flynn [rapporteur]
in Council of Europe Parliamentary Assembly, 24/06/10)

Regardless of the accuracy, or otherwise, of such comparisons in a scientific sense,

these claims served to contest the WHOs strong optimism in regards to vaccine use,
which led to the investigation of the WHOs institutional processes.
In contrast to the WHOs account, the Council of Europe presented vaccines as
not only unnecessary, but also fundamentally ineffective:
. . . it is clear that the performance of the vaccines in healthy adults is nothing to get
excited about; on average, perhaps 1 adult out of a 100 vaccinated will get influenza
symptoms compared to 2 out of 100 in the unvaccinated group. To put it another
way we need to vaccinate 100 healthy adults to prevent one set of symptoms.
However, our Cochrane review found no credible evidence that there is an effect
against complications such as pneumonia or death. (Jefferson, 29/03/10)

Moreover, in stark contrast to the WHOs narrative (and emphasis on vaccines), the
Council of Europe argued that other public health measures were more efficacious:
Public health interventions such as hygiene measures and barriers have a much better
evidence base than vaccines. They are also cheaper and socially acceptable, as well as
being life savers in poor countries, yet they are almost ignored. (Jefferson, 29/03/10)

Thus, the Council of Europe critics suggested that the WHOs (path dependent)
reliance on mass vaccination did not constitute the most valid response, even if the
H1N1 pandemic had presented a significant threat (which they also argued was not
the case).
Finally, the WHOs account of H1N1 vaccines as safe was also challenged by the
Council of Europe. Wolfgang Wodarg, the lead critic in the Council of Europes
claims, suggested that the H1N1 vaccines were not merely dangerous, but also
unnecessary. This account was mobilised because the vaccine manufacturers

Policy Studies 393

produced the H1N1 vaccines through a relatively novel procedure (which had not yet
sustained a mass vaccination campaign). Wodarg suggested that the vaccines:
. . . involved higher risks than usual vaccines against seasonal flu in [that] some
adjuvants were added and injected of which we know, that they stimulate the immune
system manifold, which means that they could possibly lead to autoimmune diseases
(such as multiple sclerosis) and immunological complications. (Wodarg, 26/01/10)

He argued further that:

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New procedures [for manufacturing the H1N1 vaccines] were allowed onto the
markets to produce vaccine products including bioreactors using fast growing
cancer-like cells. The possibility that their proteins could induce cancer when injected
involuntarily as impurities to the patient has never been excluded from clinical
testing, that needs a much longer observation period . . . (Wodarg, 26/01/10)

Despite the sensationalist nature of these claims, such narratives, through their very
existence, helped to inform the public debate surrounding H1N1, which in turn
served to challenge the WHOs construction of events, and particularly the
organisations emphasis on vaccines.
By 24 June 2010, following a series of debates, the Council of Europe had passed
a motion in its parliamentary assembly entitled Faked Pandemics: A Threat to
Public Health? criticising the WHOs handling of H1N1. Overall, the investigation
by the Council of Europe precipitated more introspection within the WHO itself; the
organisation was forced to examine its processes and assumptions. This occurred
through the external review of the WHOs pandemic response by the International
Health Regulations Review Committee (the first such assessment of the WHOs
actions in disease management) (WHO 2011). This included an acknowledgement of
the way in which prior disease events and institutional management techniques
framed the WHOs response to H1N1 (Chan, 05/05/11).
Whether the WHO will act in a more conscious (less path dependent) manner in
relation to future global health threats remains to be seen. However, the reaction of
the Council of Europe, and the WHOs subsequent assessment of its actions,
demonstrates the way in which path dependent organisations may still be susceptible
to change. This article has argued that institutional change is possible when outside
actors serve to destabilise and highlight an organisations path dependent tendencies.
Such exogenous interventions then produce an endogenous evaluation of processes.

Conclusion
The case study of the WHOs management of the H1N1 pandemic provides a useful
means through which to examine theories of path dependency. The case study reveals
that the distinctions between institutional and discursive path dependencies are
artificial. The WHO was clearly path dependent in its use of vaccines in managing
H1N1. However, this path dependency contained both discursive and historical
institutional elements. In this case, institutional processes in managing vertical
disease campaigns were a function of prior campaigns which had utilised vaccines in
an effective manner. Furthermore, this was interrelated with an organisational
discourse surrounding the efficacy of vaccines against infectious disease threats,

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394 S. Abeysinghe
which also served to reinforce the WHOs decision-making in the case of H1N1. In
this way, the WHOs management of H1N1 can be understood theoretically as
combination of institutional and discursive path dependencies.
The case also shows that change can potentially occur regardless of the path
dependent tendencies of an organisation, through relationships with external actors.
Although, internally, path dependency might characterise an institutions processes,
this do not preclude the destabilisation of these processes by outside actors. The
WHOs handling of H1N1 provides an example of where such events occurred, as the
intervention of the Council of Europe caused the WHO to be more reflexive about its
procedures and discourse.
Particularly given the inherent of risk and scientific uncertainty present in the
management of contemporary global problems, institutional processes are pivotal to
decision-making. Through the example of the WHO, this article demonstrates that
theories of institutionalism are essential in understanding the management of
contemporary risks. In highlighting and recognising the relationship between
institutional and discursive path dependencies, such theories become more widely
applicable and less rigidly theoretically bound. Theories of path dependency are of
relevance not just to the study of disease management, but in terms of the analysis of
the actions and management strategies of other NGOs and organisations,
particularly those that manage and act within contexts of risk, where a sociological
focus on organisational processes is essential.
Note
1. As might be presumed, it has been argued that the reason for the dependence on
vaccination as a strategy against malaria, despite the fact that vaccines against parasites are
generally unsuccessful, tend to be socio-political rather than purely biological/scientific.
(e.g. Turnbull 1989).

Notes on contributor
Sudeepa Abeysinghe is a Lecturer in Medical Anthropology in the School of Archaeology and
Anthropology, Australian National University, and a Postdoctoral Fellow in the School of
Sociology, Australian National University.

References
Abath, F.G.C., Montenegro, S.M.L., and Gomes, Y.M., 1998. Vaccines against human
parasitic diseases: an overview. Acta tropica, 71 (3), 237
254.
Baker, M. and Fidler, D.P., 2006. Global public health surveillance under new international
health regulations. Emerging infectious diseases, 12 (7), 1058
1655.
Beigbeder, Y., 1998. The World Health Organization. The Hague, The Netherlands: Martinus
Nijhoff.
Beverley, P.C.L., 2002. Immunology of vaccination. British medical bulletin, 62 (1), 15
28.
Blyth, M., 2003. Structures do not come with an instruction sheet: interests, ideas, and
progress in political science. Perspectives on politics, 1 (4), 695
706.
Blyth, M., 2007. Powering, puzzling, or persuading? The mechanisms of building institutional
orders. International studies quarterly, 51 (4), 761
777.

Downloaded by [LSE Library Services] at 08:51 31 October 2015

Policy Studies 395

Brown, T.M., Cueto, M., and Fee, E., 2006. The World Health Organization and the transition
from international to global public health. American journal of public health, 96 (1),
62
72.
Campbell, J.L., 2010. Institutional reproduction and change. In: G. Morgan, J.L. Campbell, C.
Crouch, O.K. Pedersen and R. Whitley, eds. The oxford handbook of comparative
institutional change. Oxford: Oxford University Press, 87
116.
Cohen, S. and Enserink, M., 2009. After delays, WHO agrees: the 2009 H1N1 pandemic has
begun. Science, 324 (5934), 1496
1497.
Corrigan, P., 1979. The World Health Organization. Hove, East Sussex: Wayland.
Dadara, A.A. and Harn, D.A., 2005. DNA vaccines against tropical parasitic disease. Expert
review of vaccines, 4 (4), 575
589.
David, P.A., 1994. Why are institutions the carriers of history?: path dependence and the
evolution of conventions, organizations and institutions. Structural change and economic
dynamics, 5 (2), 205
220.
Djelic, M., 2010. Institutional perspectives
working towards coherence or irreconcilable
diversity? In: G. Morgan, J.L. Campbell, C. Crouch, O.K. Pedersen and R. Whitley, eds. The
Oxford handbook of comparative institutional analysis. Oxford: Oxford University Press, 15

40.
Elling, R.H., 1981. The capitalist world-system and international health. Journal of health
services, 11 (1), 21
51.
Fee, E., Cueto, M., and Brown, T.M., 2008. WHO at 60: snapshots from its first six decades.
American journal of public health, 98 (4), 630
633.
Ferguson, N.M., et al., 2005. Strategies for containing an emerging influenza pandemic in
Southeast Asia. Nature, 437 (7056), 209
214.
Ferguson, N.M., et al., 2006. Strategies for mitigating an influenza pandemic. Nature, 442
(7101), 448
452.
Fidler, D.P., 2001. The globalization of public health: the first 100 years of international health
diplomacy. Bulletin of the World Health Organization, 79 (9), 842
849.
Funtowicz, S.O. and Ravetz, J.R., 1994. Uncertainty, complexity and post-normal science.
Environmental toxicology and chemistry, 13 (12), 1881
1885.
Greenwald, H.P., 2008. Organizations: management without control. Thousand Oaks: Sage.
Hall, P.A., 2010. Historical institutionalism in rationalist and sociological perspective. In:
J. Mahoney and K. Thelen, eds. Explaining institutional change. Cambridge: Cambridge
University Press, 204
224.
Hall, P.A. and Taylor, R.C.R., 1996. Political science and the three new institutionalisms.
Political studies, 44 (5), 936
957.
Hay, C. and Wincott, D., 1998. Structure, agency and historical institutionalism. Political
studies, 46 (5), 951
957.
Janes, C.R. and Corbett, K.K., 2009. Anthropology and global health. Annual review of
anthropology, 38, 167
183.
Jasanoff, S., 2004a. The idiom of co-production. In: S. Jasanoff, ed. States of knowledge: the
co-production of science and social order. London: Routledge, 1
12.
Jasanoff, S., 2004b. Ordering knowledge, ordering society. In: S. Jasanoff, ed. States of
knowledge: the co-production of science and social order. London: Routledge, 13
45.
King, N.B., 2002. Security, disease, commerce: ideologies of postcolonial global health. Social
studies of science, 32 (5
6), 763
789.
Lee, K., 2003. Introduction. In: K. Lee, ed. Health impacts of globalization: towards global
governance. Basingstoke: Palgrave Macmillan, 1
13.
Lee, K., 2005. Globalisation and health: an introduction. New York, NY: Palgrave McMillan.
Levidow, L., 2001. Precautionary uncertainty: regulating GM crops in Europe. Social studies
of science, 31, 842
874.
Lowndes, V., 2002. Institutionalism. In: D. Marsh and G. Stroker, eds. Theory and methods in
political science. 2nd ed. Basingstoke: Palgrave Macmillan, 90
108.
Lowndes, V., 2010. The institutional approach. In: D. Marsh and G. Stroker, eds. Theory and
methods in political science. 3rd ed. Basingstoke: Palgrave Macmillan, 60
79.

Downloaded by [LSE Library Services] at 08:51 31 October 2015

396 S. Abeysinghe
Lynch, M., 2004. Circumscribing expertise: membership categories in courtroom testimony.
In: S. Jasanoff, ed. States of knowledge: the co-production of science and social order.
London: Routledge, 161
180.
Mack, E., 2006/7. The World Health Organizations new international health regulations:
incursions on state sovereignty and ill-fated response to global health issues. Chicago journal
of international law, 7 (1), 365
377.
Mahoney, J., 2000. Path dependence in historical sociology. Theory and society, 29, 507
548.
Mahoney, J. and Thelen, K., 2010. A theory of gradual institutional change. In: J. Mahoney and
D. Tannen, eds. Explaining institutional change. Cambridge: Cambridge University Press, 1
37.
Marshall, B.K. and Picou, J.S., 2008. Postnormal science, precautionary principle, and
worst cases: the challenge of twenty-first century catastrophes. Sociological inquiry, 78 (2),
230
247.
Moynihan, R., 2002. Disease-mongering: how doctors, drug companies, and insurers are
making you sick. British medical journal, 324, 923.
Moynihan, R., Health, I., and Henry, D., 2002. Selling sickness: the pharmaceutical industry
and disease mongering. British medical journal, 324, 886
891.
Nowotny, H., 2003. Re-thinking science: from reliable knowledge to socially robust knowledge. In: W. Lepenies, ed. Entangled histories and negotiated universals: centres and
peripheries in a changing world. Frankfurt: Campus, 14
31.
Ollila, E., 2005. Global health priorities
priorities of the wealthy? Globalization and health,
1 (6), 6
11.
Pierson, P., 2000. The limits of design: explaining institutional origins and change. Governance,
13 (4), 475
499.
Ravetz, J., 2004. The post-normal science of precaution. Futures, 36 (3), 347
357.
Rothstein, H., 2006. The institutional origins of risk: a new agenda for risk research. Health,
risk & society, 8 (3), 215
221.
Rothstein, H., Huber, M., and Gaskell, G., 2006. A theory of risk colonization: the spiralling
regulatory logics of societal and institutional risk. Economy and society, 35 (1), 91
112.
Saloranta, T., 2001. Post-normal science and the global climate change issue. Climatic change,
50 (4), 395
404.
Schmidt, V.A., 2008. Discursive institutionalism: the explanatory power of ideas and
discourse. Annual review of political science, 11, 303
326.
Schmidt, V.A., 2010. Taking ideas and discourse seriously: explaining change through
discursive institutionalism as the fourthnew institutionalism. European political science
review, 2 (1), 1
25.
Shackley, S. and Wynne, B., 1996. Representing uncertainty in global climate change science
and policy: boundary-ordering devices and authority. Science, technology & human values,
21 (3), 275
302.
Silverman, M., 1976. The drugging of the Americas. Berkeley: University of California Press.
Taylor, A.L., 2005. Governing the globalization of public health. Journal of law, medicine &
ethics, 32 (3), 500
508.
Turnbull, D., 1989. The push for a malaria vaccine. Social studies of science, 19 (2), 283
300.
Vance, M.A. and Millington, W.R., 1986. Principles of irrational drug therapy. Journal of
health services, 16 (3), 355
362.
von Schomberg, R., 1993. Controversies and political decision making. In: R. von Schomberg,
ed. Science, politics and morality: scientific uncertainty and decision making. Dordrecht:
Kluwer, 7
10.
WHO, 2007. Working for health: an introduction to the World Health Organization. Genveva:
WHO.
Williams, S.J., Gabe, J., and Davis, P., 2008. The sociology of pharmaceuticals: progress and
prospects. Sociology of health & illness, 30 (6), 813
824.
Woodward, D. and Smith, R.D., 2003. Global public goods and health: health economic and
public health perspectives. In: R. Smith, R. Beaglehole, D. Woodward and N. Drager, eds.
Global public goods for health: health economic and public health perspectives. New York:
Oxford University Press, 3
32.

Policy Studies 397

Downloaded by [LSE Library Services] at 08:51 31 October 2015

Cited data sources

Ben Embarek, P. 03/05/09. WHO Press Briefing 03/05/09, available at: http://www.who.int/
mediacentre/multimedia/swineflupressbriefings/en/index.html
Council of Europe Parliamentary Assembly 24/06/10. Verbatim Report
Twenty-Sixth Sitting
of the Parliamentary Assembly of the Council of Europe. [online] available at: http://assembly.
coe.int/Main.asp?/Documents/Records/2010/E/10062441500.htm
Chan, M. 05/05/11. Implementation of the International Health Regulations (2005): Report of
the Review Committee on the Functioning of the International Health Regulations (2005)
in Relation to Pandemic (H1N10 2009
Report by the Director-General. Report made to
the 64th World Health Assembly. [online] available at: http://apps.who.int/gb/ebwha/pdf_
files/WHA64/A64_10-en.pdf
Flynn, P. 2010. The Handling of the H1N1 Pandemic: More Transparency Needed. [Doc no.
12283
Passed by the Council of Europe 24/06/10] Strasbourg: Social Health and Family
Affairs Committee, Council of Europe.
Fukuda, K. 24/9/09. WHO Press Briefing 24/09/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
Fukuda, K. 01/05/09. WHO Press Briefing 01/05/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
Fukuda, K. 03/12/09. WHO Press Briefing 03/12/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
Fukuda, K. 26/04/09. WHO Press Briefing 26/04/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
Fukuda, K. 05/11/09. WHO Press Briefing 05/11/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
Fukuda, K. 11/05/09. WHO Press Briefing 11/05/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
Fukuda, K. 06/05/09. WHO Press Briefing 06/05/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
Jefferson, T. 29/03/10. Speech
Dr. Tom Jefferson, The Cochrane Collaboration. [online]
available at: mms://coenews.int.vod/100329_w01_w.wnv
Kieny, M-P. 19/11/09. WHO Press Briefing 19/11/09, available at: http://www.who.int/
mediacentre/multimedia/swineflupressbriefings/en/index.html
Kieny, M-P. 06/08/09. WHO Press Briefing 06/07/09, available at: http://www.who.int/
mediacentre/multimedia/swineflupressbriefings/en/index.html
Kopacz, E. 29/03/10. Address of Ms. Ewa Kopacz, Minister of Health of Poland to the Council
of Europe. [online] available at: mms://coenews.int.vod/100329_w01_w.wnv
Shindo, N. 12/05/09. WHO Press Briefing 12/05/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
Shindo, N. 12/11/09. WHO Press Briefing 12/11/09, available at: http://www.who.int/media
centre/multimedia/swineflupressbriefings/en/index.html
WHO. 2009. Pandemic Influenza Preparedness and Response: A WHO Document. Geneva:
Global Influenza Programme, Health Security and Environment Cluster, WHO
WHO. 2011. International Health Regulations: External Review of Pandemic Response. [online]
available at: http://www.who.int/ihr/review_committee/en/index.html
Wodarg, W. 26/01/10 Hearing on The Handling of the H1N1 Pandemic More Transparency
Needed? [online] available at: http://www.coe.int/t/DC/Files/PA_session/jan_2010