I’ve talked about multi-drug resistant tuberculosis on this site before, but I want to return to the topic because of some recent articles on the topic covered on NPR. Last year there was some good news about tuberculosis globally, as researchers found that the total number of cases was declining, particularly in China. A new national tuberculosis survey in China this year, however, reveals that 10% of all new cases of tuberculosis diagnosed that country are multi-drug resistant, while 8% of these cases were infected with XDR, or extensively drug resistant tuberculosis. For these people, the treatment options are limited, and may not be successful. The article in the New England Journal of Medicine described the problems within the Chinese health care system that are driving this problem. But these challenges sound very similar to difficulties in other nations, including India and South Africa …
The World Health Organization is an under-appreciated institution, which often takes on critical tasks. For example, in 2011 it brokered an agreement to end a controversy about viral sample sharing particularly related to avian influenza. This agreement will greatly help with the development of pre-pandemic vaccines, but such achievements attract little press coverage. The WHO receives much more press when it acts as the world’s medical sleuth. When invited, it quickly arrives on the scene wherever a new disease is emerging. At the moment there are no fewer than three new diseases that merit the WHO’s attention. Although they may not each be the next SARS, they all have worrisome aspects.
There seem to be a plethora of new capitals emerging around the globe. South Sudan is planning a new
bangkok at night, courtesy of Sura Nualpradid at freedigitalphotos.net
capital in Ramciel, even as it suffers from ethnic conflict, and the myriad challenges of creating a new state. In 2005 Myanmar (Burma) created a new capital called Naypidaw, which already has nearly a million people. Although there are many explanations for the rationale behind the move (one involving an astrologer) the most likely was that this was intended to increase the military’s control. In 1997 Kazahkstan moved its capital to Astana, 600 miles away on the steppe, although few besides President Nazarbayev were enthusiastic about the idea. Angola, now one of the world’s fastest growing economies, faces problems with its capital, Luanda, which is the most expensive city in the world. As Africa’s largest oil exporter, it also has the resources to fund dreams, one of which has been the idea of creating a new capital.
In our book and this blog we give considerable attention to the threat posed by avian influenza, which also attracts a great deal of media coverage. But there is another, and older, threat that also deserves attention. Tuberculosis has been a growing problem. As Paul Farmer’s work has described, it flourished in Russia after the collapse of the Soviet Union, and drug resistant tuberculosis has been a growing threat from Peru to Haiti. The challenge is that if patients are not properly diagnosed, or if they fail to take a long course (a minimum of six months) of medication, the disease becomes resistant.
"Bacteria" by ddpavumba at freedigitalphotos.net
This problem has combined with the spread of HIV/AIDS, which decreases people’s resistance to TB. This led to a terrifying outbreak in KwaZulu-Natal province of South Africa, where an epidemic of extensively drug resistant (XDR) tuberculosis (TB) began spreading in 2006. From South Africa, the disease was moved into neighboring countries, such as Lesotho.
A recent news article in South Africa gives some insight into why TB was so difficult to treat. After a woman was diagnosed with XDR TB, she required intensive, inpatient care. Her family had to conduct a (successful) fund-raising campaign before she could be admitted to a hospital, where she is finally receiving the care she needs. In this case, the woman’s family rose to the challenge, and obtained care for her. But what if she had not been so fortunate? …
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.
Influenza Virus by renjith krishnan at freedigitalphotos.net
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. …
