Pandemic preparedness is a tricky question in global health governance. How do you create a framework that will ensure the global public good, in a context in which if every country follows its national interest, all nations may wind up in a worse position than if they cooperated? What makes influenza a challenging problem to address is its episodic nature. The last highly lethal pandemic was in 1918. In 2007 the mortality from avian flu in Indonesia was 87%. This means that the global community needs to prepare for this threat, but it cannot know when a pandemic may begin. For other diseases –malaria, tuberculosis, and HIV/AIDS- there is an alphabet soup of non-governmental organizations that advocate for those who are ill or at risk. These don’t exist for influenza, because of its episodic nature, which makes influenza a distinct global health governance issue. For this reason, the World Health Organization may not be able to prepare for a pandemic on its own, although it would certainly have authority once a pandemic had begun. Within the current framework, there seems no way to address the current stand-off regarding viral seed stock sharing, which threatens to create “rogue states” out of nations such as Indonesia. In this sense, a rogue state is a nation that acts outside the framework of international law and practice, although this definition is always also political. Currently, the United States is trying to identify next-generation vaccine technologies that will create more vaccine in a faster fashion. This will help, but there is no technological solution to this ethical and political problem.
One example illustrates this point. In order to create pre-pandemic vaccines, global health authorities need access to virus samples from regional outbreaks. But countries that have avian flu outbreaks may not benefit from the vaccine, which means that they are sometimes unwilling to share this seed stock. In 2007 Indonesia decided to not share viral samples with the World Health Organization, and instead to make a private deal with a vaccine manufacturer. Indonesia was frustrated that viral samples it had shared with the World Health Organization had been shared with pharmaceutical companies to create vaccines, and that some companies allegedly intended to patent sections of the virus’s genome. For this reason, the nation tried to reach an arrangement with Baxter Healthcare, in which Indonesia would exchange viral samples in return for inexpensive access to vaccine, as well as other assistance to prepare the nation for a pandemic. Developed countries harshly criticized Indonesia’s decision, which was depicted it as a “rogue state” in the global health system. But Indonesia argued that the 1992 Convention on Biological Diversity gave it control over genetic material from within its borders, thus creating the idea of “viral sovereignty.” From Indonesia’s perspective, they were cutting out the middleman, the World Health Organization, as part of an effort to ensure better access to vaccine for their population.
This argument attracted support from other developing countries, which saw little benefit from sharing virus samples with the World Health Organization. They perceived that these samples were being shared improperly with vaccine manufacturers that used them to create vaccines for profit, which were then sold at prices far to high for the developing world to purchase. At a meeting of the World Health Assembly in May 2007 twenty countries passed a resolution sympathetic to Indonesia’s concerns, which called for a new and fairer framework for pandemic preparedness. In the end, the World Health Organization engaged Indonesia in a conversation, which ultimately led it to return to sharing viral samples, although on an intermittent basis.
Despite this partial resolution, serious ethical issues remain with the current framework for pandemic preparedness. Developed countries have advance contracts with pharmaceutical companies, which ensure that most of the vaccine produced in a pandemic would go to these wealthy nations. Most of the factories for vaccine production are located in these same countries. This leaves developed countries depending on the charity of wealthy nations, even though the majority of avian flu (H5N1) is currently circulating in poorer countries such as Egypt, Indonesia and Vietnam. This reality was brought home during the 2009 Swine Flu (H1N1) pandemic. Although the World Health Organization solicited promises from vaccine manufacturers that they would provide 120 million doses of vaccine to poor nations, these only became available after the flu had peaked in the Global North. In the meantime, developing countries were left to their own resources. The United States’ decision not to use an adjuvant (which increases the potency of vaccine) may have been politically wise given popular mistrust of vaccines, but it also meant that there was less vaccine available. It was clear that the concerns that developing countries had expressed at the 2007 World Health Assembly had not been resolved. While wealthy countries might feel that they have nothing to lose from maintaining the status quo, the current structure raises the question: would poor nations share viral seed stocks in a genuine crisis? Or would they try to obtain the most vaccine possible for their people by any means necessary, including side arrangements with vaccine manufacturers? And what would be the political costs in a pandemic, if the Global North had vaccines, while millions died in developing countries? As we’ve recently seen in Japan, disasters have a way of escalating, when a natural catastrophe turns into an industrial disaster. A similar process could take place during a pandemic, in which a biological threat could lead to a political crisis at the nation-state level, which escalates into an economic and security crisis at the global level.
The best means to address this issue is to increase vaccine production in the developing world, particularly in those countries currently most affected by avian flu, such as Indonesia. Certainly foreign aid from rich countries can help in this area. But realistically, there is only one international organization that can take a lead role in this effort, the World Bank. In the 1990s, the World Bank played a pivotal role in HIV/AIDS treatment in Brazil through two major loans (see my book from UNC, The AIDS Pandemic in Latin America). Any effort to increase influenza vaccine production in the developing world cannot only focus on pandemic production, given that no-one knows when an outbreak might begin. This means that in addition to creating factories to produce vaccine, this effort will also inevitably entail building the health system that will create and deliver influenza vaccine annually in these nations. This would be an expensive endeavor, but one that could be achieved with existing resources if it were a priority. This would address the ethical issues involved in pandemic preparedness, while also serving the national interest that developed countries have in maintaining access to viral seed stock samples. Recent events in Japan have public policy implications globally, as nations rethink nuclear energy. In the same way, we need to be aware of how crises in South East Asia could have major implications for global health, which could affect us all.
For more information on global health issues, please see the health chapter in our book. But I want to apologize for one embarrassing mistake in this section. In discussing the 1918 pandemic, I meant to say that such leaders as Woodrow Wilson may have been infected during the influenza pandemic, not that they had died of it (John Barry, The Great Influenza, 387). Woodrow Wilson died in 1924, and not from the flu. I don’t know of any leaders of a major world power who died during the 1918 pandemic.
To everyone who wants a sense of why influenza is such a frightening virus, I strongly recommend John Barry’s, The Great Influenza: the Story of the Deadliest Pandemic in History as well as Alfred Crosby’s America’s Forgotten Pandemic.
Shawn Smallman, Portland State University