Has Primary Health Care become a Global Orphan

Has PHC Become a Global Orphan?, Anthony Seddoh, Pambazuka News 398, 9/25/08
With progress towards quality primary health care still slow some thirty years after Alma-Ata, Anthony Seddoh writes that an effective global alliance of global and country actors needs to set positive and realistic paths to implement the declaration’s intentions. In light of the continuing absence of a conceptual framework for addressing longstanding debates and organisational issues, the author considers whether primary health care represents a global orphan in need of fresh guardianship.
Thirty years after the 1978 Declaration of Alma-Ata, it seems the world is still at odds on how best to implement the principles of primary health care. The slow progress in improving health outcomes for all raises questions about the effectiveness of current ways of doing business. A concerted global alliance of global and country actors needs to set positive and realistic paths to implement the intentions of Alma-Ata.
Sixty years ago, the World Health Organization (WHO) stated in its constitution that health is ‘a state of physical, mental and social wellbeing, not only the absence of disease or infirmity.’ Thirty years later, the Alma-Ata declaration on Primary Health Care (PHC) declared among other things that ‘health is a fundamental right’ and created a thirteen-point outline to ensure this right. This outline captured concepts of essential care, universally accessibility and affordability for individuals and families within communities, who would be able to participate fully in a spirit of self-determination.
It located PHC as an integral part of a country’s health system involving all related sectors and aspects of national and community development.
The WHO constitution’s definition of health and the Alma-Ata declaration together prompt a diametrical but complementary state to be addressed concurrently in the promotion of good health. The first deals with the clinical determinants of health, pushing for the absence of disease in individuals. The second addresses the determinants of health that predispose or prevent individuals from attaining a state of mental, physical and social wellbeing as a fundamental right. These include appropriate governance, the absence of war, economic and infrastructure development, adequate infrastructure and aid policies. A unique moment occurred in 1978 to bring these complementary understandings together.
Even before the ink could dry on the Alma-Ata declarations it had however already generated polarised antagonism. From a capitalist standpoint, it was a ridiculous proposition, both too costly and defying economic reasoning, and too socialist in its excessive emphasis on state-managed intervention. The conservative duo of J.A. Walsh and K.S. Warren launched the Selective PHC debate, arguing that it would probably more be efficient to save children and limit population growth, while the two main PHC proponents, WHO and UNICEF, soon drifted apart, with UNICEF promoting a selective package of low cost interventions. With resource flows following Selective PHC, Primary Health Care translated in most countries into a basic collection of services to be delivered at district and community levels based on a select number of interventions with some outreach services, with an accompanying watered-down district health package.
Why nobody asked at the time whether there was any moral significance to be attached to a person’s life or pointed out that choices based on state preferences for total health gain can be justified over financial resource allocation efficiency is difficult to comprehend. Aside from efficiency-based arguments being ridiculous propositions founded on utility-based preferences or embodying unattractive equity assumptions, the economic bargain in a healthy population should at least have also appealed to responsible international choice.
Much has since been achieved from the advance in technology in dealing with specific clinical determinants of specific diseases. It could be argued that a saturation point has been reached, where increases in financial and human investments in existing technologies are yielding less than proportional gains. Despite this the selective interventions approach continues to define health and health services delivery. It was given a new lease on life by the World Bank through its 1993 World Development Report, entitled ‘Investing in Health’. This report, which scarcely acknowledged PHC, commoditised and de-linked health from development and moved the world closer to an interventionist approach to health; intervening at a selective point in the epidemiology of a disease or health system.
This approach has since had wide global appeal. Currently there are over thirty WHO resolutions on AIDS, TB or Malaria alone; more than all other subjects. The Millennium Development Goals (MDGs) have further entrenched this disease-specific approach to resource mobilisation. There are over 80 major global health initiatives linked to the health MDGs, providing over US$100 million annually. The Italian Global Health Watch reported in 2008 that the Global Fund has allocated approximately US$3.5 billion to countries for interventions on AIDS, TB and Malaria, mainly in Africa. Together, these initiatives have thrown billions of dollars at addressing diseases and improving clinical health conditions and made up a significant part of health sector budgets.
PHC is hardly mentioned in these initiatives, seldom highlighted by member states outside of anniversaries of the initiatives or occasional references to district health system strengthening. For various reasons the world assumed an emergency mode to address what are considered new and urgent public health issues. Single disease interventions that lend themselves to easily recognisable financial accountability, quantitative monitoring and evaluation held greater appeal for funders, especially when twinned with arguments of weak domestic governance and public policy failures and capacity limitations.
While these initiatives on clinical determinants hummed with measurable outcomes on specific diseases, the nexus of poverty and ill health was exacerbated. On the back of a growing trend in urban slum development, decline in state services, market failures in privatised economies, growing food insecurity and massive deprivation of rights to health care, inequalities in health have deepened to a significantly greater level over the past 30 years.
Hence while a lot has been done to deal with disease in individuals, the unique opportunity provided by the Alma-Ata Declaration to also address the determinants of health have largely been lost. Thirty years later we see the costs of this omission in levels of poverty which belie the levels of knowledge and technological advance achieved globally.
As we approach another anniversary for PHC expectations are high. People expect that their physical and mental health will be promoted in a safe social, economic and political environment. They expect to have quality health systems that provide preventive services, and which diagnose, treat and manage disease injury and reduce the severity and repeated occurrence of disease. They do not expect to see wide social and economic disparities in these basic entitlements. In Africa, the region furthest from delivery on these expectations, the Ouagadougou declaration on Primary Health Care issued on April 30 2008 called for a renewal of the Principles of Primary Health Care and its implementation in developing countries and by the international community.
Such declarations are encouraging, yet their implementation calls for resolution of longstanding debates of the past 30 years. These debates are not academic. In choices made over policy measures, relative allocation of institutional, social and financial resources and complementary systems for dealing with the social determinants of health (mostly dealt with by actions outside the health sector), they present social and economic inequalities that arise due to the burden of disease (mostly dealt with within the health sector). There are no clear answers for how a conceptual framework of Primary Health Care in 2008 will address this.
And while there is a massive coalition of global initiatives dealing with diseases, there is no clear coalition of global institutions supporting or funding the determinants of health, the second factor in the PHC equation. At a global level, the Bretton Woods institutions and OECD initiatives for debt relief and poverty reduction have in some African countries led to short-lived increases in spending on health and education, with no global initiatives so far adequately addressing the determinants of health.
This leaves PHC as an orphan with no global guardian. The WHO’s attempt to foster PHC is inadequate given the pluralistic global environment. The state of poverty and the winds of change in international health resource priorities will make rational choices among the various dimensions impossible and predispose countries to the dictate of new interventions and their implementation. While debates over the conceptual understanding of PHC will not end in 2008, this year could at least mark the turning point for a new institutional response, one that builds a global alliance to generate the momentum and support for countries to implement PHC and that provide policy learning based on practice from the bottom up, reminiscent of another basis for the Alma-Ata declaration.
A WHO or UN resolution creating such a global alliance would be a befitting PHC birthday gift for the millions of people seeking more than another conference. It will squarely put implementation right at the doorstep of a recognisable entity that can mobilise the needed funds and offer effective support to individual countries.

Washington Post article

Check out the website to read about, "For a Global Generation, Public Health is a hot field"

http://www.washingtonpost.com/wp-dyn/content/article/2008/09/18/AR2008091804145.html?referrer=emailarticle

Conference Subcommittee report

Heartland Global Health Consortium
Conference Subcommittee


The Central College house is reserved for consortium use from January 3- January 10, 2009. The original instruction to the committee was to plan a six- or seven-day conference, but several members of the subcommittee have suggested that a shorter conference might be more attractive to potential participants. Two proposed schedules are provided at the conclusion of this document, and the subcommittee invites comment from other consortium participants.

The Central College property in Merida includes a large house (a former governor’s mansion) with 9 bedrooms and 5 bathrooms. The bedrooms are very large and can accommodate up to 4 people each. There are several gathering spaces, both inside and outside. A palapa (classroom that is outdoors, but covered) seats at least 30 people. Several large and small patios and decks are also well suited for small group discussions.

Central College is willing to provide accommodation, including lodging, all meals, field trip transportation costs, etc. for a fee of $500 per person or less, depending on which schedule we choose. Some consortium members may choose to lodge at a nearby hotel (we will provide costs and other details in the near future). Discussions with Valerie Grimsley, Central College program director in Merida suggest that the optimal number of participants for this conference is no more than 30.

Objectives for the conference are:

Speakers/Sessions Days: To educate ourselves about the most pressing issues and approaches that are of current and future concern to scholars and professionals working in the field of global public health.
Field Trips: To explore how public health issues of pressing concern are addressed in both rural and urban settings in Merida and surrounding communities. To consider ways in which transnational influences on these communities either exacerbate or ameliorate public health problems.
Planning Day: To consider ways in which the consortium can best serve to strengthen faculty and student interest and learning with respect to global public health at member institutions. Focus on concrete plans for collaboration according to the division of labor represented by our present committee structure.





See next page for proposed schedules


Schedule Option 1
(4 days plus travel)

Day 1: Travel (reception or other activity in evening, depending on flight availability)
Day 2: Field trip to rural village, followed by siesta, discussion, and reflection
Day 3: Presentations from local experts and public health officials
Day 4: Field trip to urban area, followed by siesta, discussion, and reflection
Day 5: Consortium strategy session
Day 6: Travel

Schedule Option 2
(6 days plus travel)


Day 1: Travel
Day 2: Orientation to Merida (market, walking tour, etc.)
Day 3: Presentations from local experts and public health officials
Day 4: Visit to urban community, reflection and discussion
Day 5: Visit to rural community, reflection and discussion
Day 6: Presentations from local experts
Day 7: Excursion to Uxmal
Day 8: Travel

Education Subcommittee report

Heartland Global Health Consortium

Education Subcommittee Report March 8, 2008

Chair: Ellie DuPre?

General Purpose:
To develop multidisciplinary educational programs that will allow students and faculty in the consortium to participate in understanding and promoting public awareness of global health issues.


Objectives:
(1) Develop a certificate program in Global Public Health
· Credit hours
· Core courses
· Elective courses

(2) Develop a Masters Degree program in Global Public Health
· Credits hours
· Core courses
· Electives courses

(3) Determine and establish matriculation protocol between all participating consortium members

(4) Determine the best means to implement the programs.
· Class availability:
– evenings
– summer
– weekends
– online


Program assumptions:
· Courses should be multidisciplinary
· Emphasis should be on significant international health issues including their (both local and global) social, political, economic and, cultural dimensions as appropriate to ensure better understanding of the availability of resources for public health in developing countries.
· Experiential learning and study abroad should be a component of the core


Discussions concerning the make up of the core and possible elective courses have begun.

Funding & Development subcommittee report

Funding and Development Committee
Report
March 7, 2008


Members: Raylene Rospond, Chair; Mary Mincer Hansen, Brian Zylstra, Hsain Ilahiane

General Purpose: Developing relationships between schools and finding funding sources for the work of the consortium.

Objectives

Information sharing
Leveraging joint resources to sustain consortium
Attracting new Resources
Advocate for Global Health education
Facilitate networking between students and Faculty t
Promote Public Awareness in Global
Share Study abroad opportunities (mix student levels
Promote Alumni Involvement
Develop Iowa Global Health Database

Activities to date


1) The Blogger user Hsain Ilahiane has invited you to contribute to the blog: Heartland Global Health Consortium.

To contribute to this blog, visit:
http://www.blogger.com/i.g?inviteID=5520353644698935498&blogID=2736134306248244043

You'll need to sign in with a Google Account to confirm the invitation and start posting to this blog. If you don't have a Google Account yet, we'll show you how to get one in minutes.


2) Initial investigation into funding opportunities

Laurie Garrett paper 3


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The Next Pandemic?
By Laurie Garrett
From Foreign Affairs , July/August 2005

Summary: Since it first emerged in 1997, avian influenza has become deadlier and more resilient. It has infected 109 people and killed 59 of them. If the virus becomes capable of human-to-human transmission and retains its extraordinary potency, humanity could face a pandemic unlike any ever witnessed.
Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations and is the author of The Coming Plague and Betrayal of Trust.

PROBABLE CAUSE
Scientists have long forecast the appearance of an influenza virus capable of infecting 40 percent of the world's human population and killing unimaginable numbers. Recently, a new strain, H5N1 avian influenza, has shown all the earmarks of becoming that disease. Until now, it has largely been confined to certain bird species, but that may be changing.
The havoc such a disease could wreak is commonly compared to the devastation of the 1918-19 Spanish flu, which killed 50 million people in 18 months. But avian flu is far more dangerous. It kills 100 percent of the domesticated chickens it infects, and among humans the disease is also lethal: as of May 1, about 109 people were known to have contracted it, and it killed 54 percent (although this statistic does not include any milder cases that may have gone unreported). Since it first appeared in southern China in 1997, the virus has mutated, becoming heartier and deadlier and killing a wider range of species. According to the March 2005 National Academy of Science's Institute of Medicine flu report, the "current ongoing epidemic of H5N1 avian influenza in Asia is unprecedented in its scale, in its spread, and in the economic losses it has caused."
In short, doom may loom. But note the "may." If the relentlessly evolving virus becomes capable of human-to-human transmission, develops a power of contagion typical of human influenzas, and maintains its extraordinary virulence, humanity could well face a pandemic unlike any ever witnessed. Or nothing at all could happen. Scientists cannot predict with certainty what this H5N1 influenza will do. Evolution does not function on a knowable timetable, and influenza is one of the sloppiest, most mutation-prone pathogens in nature's storehouse.
Such absolute uncertainty, coupled with the profound potential danger, is disturbing for those whose job it is to ensure the health of their community, their nation, and broader humanity. According to the Centers for Disease Control and Prevention (CDC), in a normal flu season about 200,000 Americans are hospitalized, 38,000 of whom die from the disease, with an overall mortality rate of .008 percent for those infected. Most of those deaths occur among people older than 65; on average, 98 of every 100,000 seniors with the flu die. Influenza costs the U.S. economy about $12 billion annually in direct medical costs and loss of productivity.
Yet this level of damage hardly approaches the catastrophe that the United States would face in a severe flu pandemic. The CDC predicts that a "medium-level epidemic" could kill up to 207,000 Americans, hospitalize 734,000, and sicken about a third of the U.S. population. Direct medical costs would top $166 billion, not including the costs of vaccination. An H5N1 avian influenza that is transmittable from human to human could be even more devastating: assuming a mortality rate of 20 percent and 80 million illnesses, the United States could be looking at 16 million deaths and unimaginable economic costs. This extreme outcome is a worst-case scenario; it assumes failure to produce an effective vaccine rapidly enough to make a difference and a virus that remains impervious to some antiflu drugs. But the 207,000 reckoning is clearly a conservative guess.
The entire world would experience similar levels of viral carnage, and those areas ravaged by HIV and home to millions of immunocompromised individuals might witness even greater death tolls. In response, some countries might impose useless but highly disruptive quarantines or close borders and airports, perhaps for months. Such closures would disrupt trade, travel, and productivity. No doubt the world's stock markets would teeter and perhaps fall precipitously. Aside from economics, the disease would likely directly affect global security, reducing troop strength and capacity for all armed forces, UN peacekeeping operations, and police worldwide.
In a world where most of the wealth is concentrated in less than a dozen nations representing a distinct minority of the total population, the capacity to respond to global threats is, to put it politely, severely imbalanced. The majority of the world's governments not only lack sufficient funds to respond to a superflu; they also have no health infrastructure to handle the burdens of disease, social disruption, and panic. The international community would look to the United States, Canada, Japan, and Europe for answers, vaccines, cures, cash, and hope. How these wealthy governments responded, and how radically the death rates differed along worldwide fault lines of poverty, would resonate for years thereafter.

WHAT ONCE WAS LOST
Nearly half of all deaths in the United States in 1918 were flu related. Some 675,000 Americans -- about 0.6 percent of the population of 105 million and the equivalent of 2 million American deaths today -- perished from the Spanish flu. The average life expectancy for Americans born in 1918 was just 37 years, down from 55 in 1917. Although doctors then lacked the technology to test people's blood for flu infections, scientists reckon that the Spanish flu had a mortality rate of just less than one percent of those who took ill in the United States. It would have been much worse had there not been milder flu epidemics in the 1850s and in 1889, caused by similar but less virulent viruses, which made most elderly Americans immune to the 1918-19 strain. The highest death tolls were among young adults, ages 20-35.
The Spanish flu got its name because Spain suffered from an early and acute outbreak, but it did not originate there. Its actual origin remains uncertain. The first strain was mild enough to prompt most World War I military forces to dismiss it as a pesky ailment. When the second strain hit North America in the summer of 1918, however, the virus caused a surge of deaths. First hit was Camp Funston, an army base in Kansas, where young soldiers were preparing for deployment to Europe. The virus then spread swiftly to other camps and on troop ships crossing the Atlantic, killing 43,000 U.S. military personnel in about three months. Despite the entreaties of the military's surgeons general, President Woodrow Wilson ordered continued shipments of troops aboard crowded naval transports, which soldiers came to call "death ships." By late September 1918, so overwhelmed was the War Department by influenza that the military could not assist in controlling civic disorder at home, including riots caused by epidemic hysteria. Worse, so many doctors, scientists, and lab technicians had been drafted into military service that civilian operations were hamstrung.
Under these conditions, influenza swept from the most populous U.S. cities to extraordinarily remote rural areas. Explorers discovered empty Inuit villages in what are now Alaska and the Yukon Territory, their entire populations having succumbed to the flu. Many deaths were never included in the pandemic's official death toll -- such as the majority of victims in Africa, Latin America, Indonesia, the Pacific Islands, and Russia (then still in the throes of revolution). What is known about the toll in these regions is staggering. For example, influenza killed 5 percent of the population of Ghana in only two months, and nearly 20 percent of the people of Western Samoa died. The official estimate of 40-50 million total deaths is believed to be a conservative extrapolation of European and American records. In fact, many historians and biologists believe that nearly a third of all humans suffered from influenza in 1918-19 -- and that of these, 100 million died.
In the last years of the nineteenth century and the early years of the twentieth, a series of important scientific discoveries spawned a revolution in biology and medicine and led pioneers such as Hermann Biggs, a New York City doctor, to create entire legal and health systems based on the identification and control of germs. By 1917, the United States and much of Europe had become enthralled by the hygiene movement. Impressive new public health infrastructures had been built in many cities, tens of thousands of tuberculosis victims were isolated in sanatoriums, the incidences of child-killing diseases such as diphtheria and typhoid fever had plummeted, and cholera epidemics had become rare events in the industrialized world. There was great optimism that modern science held the key to perfect health.
Influenza's arrival shattered the hope; scientists still had virtually no understanding of viruses generally, and of influenza in particular. The hygienic precautions and quarantines that had proved so effective in holding back the tide of bacterial diseases in the United States proved useless, even harmful, in the face of the Spanish flu. As the epidemic spread, top physicians and scientists claimed its cause was everything from tiny plants to old dusty books to something called "cosmic influence." It was not until 1933 that a British research team finally isolated and identified the influenza virus.
Most strains of the flu do not kill people directly; rather, death is caused by bacteria, which surge into the embattled lungs of the victim. But the Spanish flu that circulated in 1918-19 was a direct killer. Victims suffered from acute cyanosis, a blue discoloration of the skin and mucous membranes. They vomited and coughed up blood, which also poured uncontrollably from their noses and, in the case of women, from their genitals. The highest death toll occurred among pregnant women: as many as 71 percent of those infected died. If the woman survived, the fetus invariably did not. Many young people suffered from encephalitis, as the virus chewed away at their brains and spinal cords. And millions experienced acute respiratory distress syndrome, an immunological condition in which disease-fighting cells so overwhelm the lungs in their battle against the invaders that the lung cells themselves become collateral damage, and the victims suffocate. Had antibiotics existed, they may not have been much help.

OOPS
In January 1976, 18-year-old Private David Lewis staggered his way through a forced march during basic training in a brutal New Jersey winter. By the time his unit returned to base at Fort Dix, Lewis was dying. He collapsed and did not respond to his sergeant's attempts at mouth-to-mouth resuscitation.
In subsequent weeks, U.S. Army and CDC scientists discovered that the virus that had killed Lewis was swine flu. Although no other soldiers at Fort Dix died, health officials panicked. F. David Matthews, then secretary of health, education, and welfare, promptly declared, "There is evidence there will be a major flu epidemic this coming fall. The indication is that we will see a return of the 1918 flu virus that is the most virulent form of flu. In 1918, a half million people died [in the United States]. The projections are that this virus will kill one million Americans in 1976."
At the time, it was widely believed that influenza appeared in cycles, with especially lethal forms surfacing at relatively predictable intervals. Since 1918-19, the United States had suffered through influenza pandemics in 1957-58 and 1968-69; the first caused 70,000 deaths and the second 34,000. In 1976, scientists believed the world was overdue for a more lethal cycle, and the apparent emergence of swine flu at Fort Dix seemed to signal that another wave had come. The leaders of the CDC and the Department of Health, Education, and Welfare (HEW) warned the White House that there was a reasonably high probability that a catastrophic flu pandemic was about to hit. But opinion was hardly unanimous, and many European and Australian health authorities scoffed at the Americans' concern. Unsure of how to gauge the threat, President Gerald Ford summoned the polio-fighting heroes Jonas Salk and Albert Sabin to Washington and found the long-time adversaries in remarkable accord: a flu pandemic might truly be on the way.
On March 24, 1976, Ford went on national television. "I have just concluded a meeting on a subject of vast importance to all Americans," he announced. "I have been advised that there is a very real possibility that unless we take effective counteractions, there could be an epidemic of this dangerous disease next fall and winter here in the United States. ... I am asking Congress to appropriate $135 million, prior to the April recess, for the production of sufficient vaccine to inoculate every man, woman, and child in the United States."
Vaccine producers immediately complained that they could not manufacture sufficient doses of vaccine in such haste without special liability protection. Congress responded, passing a law in April that made the government responsible for the companies' liability. When the campaign to vaccinate the U.S. population started four months later, there were almost immediate claims of side effects, including the neurologically debilitating Guillain Barré Syndrome. Most of the lawsuits -- with claims totaling $3.2 billion -- were settled or dismissed, but the U.S. government still ended up paying claimants around $90 million.
Swine flu, however, never appeared. The head of the CDC was asked to resign, and Congress never again considered assuming the liability of pharmaceutical companies during a potential epidemic. The experience weakened U.S. credibility in public health and helped undermine the stature of President Ford. Subsequently, an official assessment of what went wrong was performed for HEW by Dr. Harvey Fineberg, a Harvard professor who is currently president of the Institute of Medicine.
Fineberg concluded:"In this case the consequences of being wrong about an epidemic were so devastating in people's minds that it wasn't possible to focus properly on the issue of likelihood. Nobody could really estimate likelihood then, or now. The challenge in such circumstances is to be able to distinguish things so you can rationally talk about it. In 1976, some policymakers were simply overwhelmed by the consequences of being wrong. And at a higher level [in the White House] the two -- likelihood and consequence -- got meshed."
Fineberg's warnings are well worth remembering today, as scientists nervously consider H5N1 avian influenza in Asia. The consequences of a form of this virus that is transmittable from human to human, particularly if it retains its unprecedented virulence, would be disastrous. But what is the likelihood that such a virus will appear?

DEVOLUTION
Understanding the risks requires understanding the nature of H5N1 avian flu specifically and influenza in general. Influenza originates with aquatic birds and is normally carried by migratory ducks, geese, and herons, usually without harm to them. As the birds migrate, they can pass the viruses on to domesticated birds -- chickens, for example -- via feces or during competitions over food, territory, and water. Throughout history, this connection between birds and the flu has spawned epidemics in Asia, especially southern China. Aquatic flu viruses are more likely to pass into domestic animals -- and then into humans -- in China than anywhere else in the world. Dense concentrations of humans and livestock have left little of China's original migratory route for birds intact. Birds that annually travel from Indonesia to Siberia and back are forced to land and search for sustenance in farms, city parks, and industrial sites. For centuries, Chinese farmers have raised chickens, ducks, and pigs together, in miniscule pens surrounding their homes, greatly increasing the chance of contamination: influenza can spread from migrating to domestic birds and then to swine, mutating and eventually infecting human beings.
Ominously, as China's GDP grows, so do the expensive appetites of the country's 1.3 billion people, more of whom can afford to eat chicken regularly. Today, China annually raises about 13 billion chickens, 60 percent of them on small farms. Chicken farming is quickly morphing into a major industry, with some commercial poultry plants rivaling those in Arkansas and Georgia in scale -- but lagging behind in hygienic standards. These factors favor rapid influenza evolution. By the close of the twentieth century, at least two new types of human-to-human flu spread around the world every year.
Influenza viruses contain eight genes, composed of RNA and packaged loosely in protective proteins. Like most RNA viruses, influenza reproduces sloppily: its genes readily fall apart, and it can absorb different genetic material and get mixed up in a process called reassortment. When influenza successfully infects a new species -- say, pigs -- it can reassort, and may switch from being an avian virus to a mammalian one. When that occurs, a human epidemic can result. The transmission cycles and the constant evolution are key to influenza's continued survival, for were it to remain identical year after year, most animals would develop immunity, and the flu would die out. This changing form explains why influenza is a seasonal disease. Vaccines made one year are generally useless the following.
Among the eight influenza genes there are two, dubbed H and N, that provide the code for proteins recognized by the human immune system. Scientists have numbered the many types of H and N proteins and use this system to classify a virus. A different viral combination of H and N proteins will trigger a different human immune response. For example, if a strain of H2N3 influenza circulates one year, followed by a different variety of H2N3 the next year, most people will be at least partially immune to the second strain. But if an H2N3 season is followed by an outbreak of H3N5 influenza, few people will have any immunity to the second virus, and the epidemic could be enormous. But a widespread epidemic need not be a severe or particularly deadly one: a virus' virulence depends on genes other than the two that control the H and N proteins.
Scientists first started saving flu virus samples in the early twentieth century. Since that time, an H5N1 influenza has never spread among human beings. According to the World Health Organization (WHO), "No virus of the H5 subtype has probably ever circulated among humans, and certainly not within the lifetime of today's world population. Population vulnerability to an H5N1-like pandemic virus would be universal." As for virulence, within about 48 hours of infection, H5N1 avian influenza kills 100 percent of infected chickens -- although the virulence of a potential human-to-human transmissible H5N1 is impossible to predict.
A team of Chinese scientists has been tracking the H5N1 virus since it first emerged in Hong Kong in 1997, killing 6 people and sickening 18 others. The strain came out of southern China's Guangdong Province, where it apparently was carried by ducks, and hit Hong Kong's chicken population hard. After authorities there killed 1.5 million chickens -- almost every single one in Hong Kong -- the outbreak seemed to stop. But the virus had not disappeared; rather, it had retreated to China's Guangdong, Hunan, and Yunnan provinces, spreading once again to aquatic birds.
From 1998 to 2001 the virus went through multiple reassortments and moved back to domestic birds, spreading almost unnoticed in Chinese chicken flocks. It continued to evolve at high speed: 17 more reassortments occurred, and in January 2003 the "Z" virus emerged, a mutant powerhouse that had become tougher, capable of withstanding a wider range of environmental challenges. The Z virus spread to Vietnam and Thailand, where it evolved further, becoming resistant to one of the two classes of antiflu drugs, known as amantadines, or M2-inhibitors.
In early 2004, it became supervirulent and capable of killing a broad range of species, including rodents and humans. That permutation of the virus was dubbed "Z+." In the first three weeks of January 2004, Z+ killed 11 million chickens in Vietnam and Thailand. By April 2004, 120 million chickens in Asia had died of flu or been exterminated to slow the influenza brushfire. The avian epidemic stopped for a while, but in July another 1 million chickens died from the disease. The Z+ virus was causing massive internal bleeding in the birds. By the beginning of 2005, with chickens dying and customers shying away from what remained, the Asian poultry industry had lost nearly $15 billion.
By April 2005, the H5N1 virus had also moved to pigs. Scientists isolated the disease from swine in a part of Indonesia where pigs are raised underneath elevated wood-slatted platforms that house chickens. Less rigorous investigations had previously indicated that pigs in China and Vietnam may also have been infected by H5N1 influenza. The discovery in Indonesia provided disturbing evidence that the virus was infecting mammals, although it was not yet known how widely the swine disease had spread or how lethal it was for the animals.

HARD TO KILL
Over the course of this brief but rapid evolution, the H5N1 virus developed in ways unprecedented in influenza research. It is not only incredibly deadly but also incredibly difficult to contain. The virus apparently now has the ability to survive in chicken feces and the meat of dead animals, despite the lack of blood flow and living cells; raw chicken meat fed to tigers in Thailand zoos resulted in the deaths of 147 out of a total of 418. The virus has also found ways to vastly increase the range of species it can infect and kill. Most strains of influenza are not lethal in lab mice, but Z+ is lethal in 100 percent of them. It even kills the very types of wild migratory birds that normally host influenza strains harmlessly. Yet domestic ducks, for unknown reasons, carry the virus without a problem, which may explain where Z+ hides between outbreaks among chickens.
Traditional Asian methods of buying, slaughtering, and cooking meat make it hard to track the spread of an influenza virus -- and tracking it is critical to preventing the disease from spreading. In Asia, consumers prefer to buy live chickens and other live animals at the market, slaughtering them in home kitchens. Asians thus have a high level of exposure to potentially disease-carrying animals, both in their homes and as they pass through the markets that line the streets of densely packed urban centers. For someone trying to trace a disease, Asia is a nightmare: with people daily exposed to live chickens in so many different environments, how can a sleuth tell whether an ailing flu victim was infected by a chicken, a duck, a migratory heron -- or another human being?
Although most of the 109 known human H5N1 infections have been ascribed to some type of contact with chickens, mysteries abound, and many cases remain unsolved. "The virus is no longer causing large and highly conspicuous outbreaks on commercial farms," a 2005 WHO summary of the human Z+ cases states. "Nor have poultry workers or cullers turned out to be an important risk group that could be targeted for protection. Instead, the virus has become stealthier: human cases are now occurring with no discernible exposure to H5N1 through contact with diseased or dead birds."
If proximity to infected animals is the key, why have there been no deaths among chicken handlers, poultry workers, or live-chicken dealers? The majority of the infected have been young adults and children. And there has been one documented case of human-to-human transmission of the Z+ strain of the H5N1 virus -- in late 2004, in Thailand. Several more such cases are suspected but cannot be confirmed. According to the WHO, there is "no scientific explanation for the unusual disease pattern."
Assessing and understanding H5N1's virulence in humans has also proved elusive. When it first appeared in Hong Kong in 1997, the virus killed 35 percent of those it was known to have infected. (Less severe cases may not have been reported.) The Z strain of the disease, which emerged in early 2003, killed 68 percent of those known to have been infected. In H5N1 cases since December 2004, however, the mortality has been 36 percent. How can the fluctuation over time be explained? One disturbing possibility is that H5N1 has begun adapting to its human hosts, becoming less deadly but easier to spread. In the spring of 2005, in fact, H5N1 infected 17 people throughout Vietnam, resulting in only three deaths. Leading flu experts argue that this sort of phenomenon has in the past been a prelude to human influenza epidemics.
The medical histories of those who have died from H5N1 influenza are disturbingly similar to accounts of sufferers of the Spanish flu in 1918-19. Otherwise healthy people are completely overcome by the virus, developing all of the classic flu symptoms: coughing, headache, muscle pain, nausea, dizziness, diarrhea, high fever, depression, and loss of appetite. But these are just some of the effects. Victims also suffer from pneumonia, encephalitis, meningitis, acute respiratory distress, and internal bleeding and hemorrhaging. An autopsy of a child who died of the disease in Thailand last year revealed that the youth's lungs had been torn apart in the all-out war between disease-fighting cells and the virus.

BAD MEDICINE
According to test-tube studies, Z+ ought to be vulnerable to the antiflu drug oseltamivir, which the Roche pharmaceuticals company markets in the United States under the brand name Tamiflu. Yet Tamiflu was given to many of those who ultimately succumbed to the virus; it is believed that medical complications induced by the virus, including acute respiratory distress syndrome, may have prevented the drug from helping. It is also difficult to tell whether the drug contributed to the survival of those who took it and lived, although higher doses and more prolonged treatment may have a greater impact in fighting the disease. A team of Thai clinicians recently concluded that "the optimal treatment for case-patients with suspected H5 infection is not known." Lacking any better options, the WHO has recommended that countries stockpile Tamiflu to the best of their ability. The U.S. Department of Health and Human Services is doing so, but supplies of the drug are limited and it is hard to manufacture.
What about developing a Z+ vaccine? Unfortunately, there is only more gloom in the forecast. The total number of companies willing to produce influenza vaccines has plummeted in recent years, from more than two dozen in 1980 to just a handful in 2004. There are many reasons for the decline in vaccine producers. A spate of corporate mergers in the 1990s, for example, reduced the number of major international pharmaceutical companies. The financial risk of investing in vaccines is also a key factor. In 2003, the entire market for all vaccines -- from polio to measles to hepatitis to influenza -- amounted to just $5.4 billion. Although that sum may seem considerable, it is less than two percent of the global pharmaceutical market of $337.3 billion. Unlike chemical compounds, vaccines and most other biological products are difficult to make and can easily become contaminated. There is also a large and litigious antivaccine constituency -- some people believe that vaccines cause harmful side effects such as Alzheimer's disease and autism -- adding considerable liability costs to manufacturers' bottom lines.
The production of influenza vaccines holds particular drawbacks for companies. Flu vaccines must be made rapidly, increasing the risk of contamination or other errors. Because of the seasonal nature of the flu, a new batch of influenza vaccines must be produced each year. Should sales in a given year prove disappointing, flu vaccines cannot be stockpiled for sale in a subsequent season because by then the viruses will have evolved. In addition, the manufacturing process of flu vaccines is uniquely complex: pharmaceutical companies must grow viral samples on live chicken eggs, which must be reared under rigorous hygienic conditions. Research is under way on reverse genetics and cellular-level production techniques that might prove cheaper, faster, and less contamination-prone than using eggs, but for the foreseeable future manufacturers are stuck with the current laborious method. After cultivation, samples of the viruses must be harvested, the H and N characteristics must be shown to produce antibodies in test animals and human volunteers, and tests must prove that the vaccine is not contaminated. Only then can mass production commence.
The H5N1 strain of avian flu poses an additional problem: the virus is 100 percent lethal to chickens -- and that includes chicken eggs. It took researchers five years of hard work to devise a way to grow the 1997 version of the H5N1 virus on eggs without killing them; although there have been technological improvements since then, there is no guarantee that an emerging pandemic strain could be cultivated fast enough.
In the current system, all influenza vaccines must be quickly made following a WHO meeting of flu experts held every February. At that gathering, scientists scrutinize all available information on the flu strains known to be circulating in the world. They then try to predict which strains are most likely to spread across every continent in the next six to nine months. (This year the WHO committee chose three human flu strains, of types H3N2 and H1N1, to be the basis of the next vaccine.) Samples of the chosen strains are delivered to pharmaceutical companies around the world for vaccine production, and the vaccines are hopefully available to the public by September or October -- a few months after influenza typically strikes Asia, in the early summer. Europe and the Americas are usually hit shortly after, in September. Because viruses constantly change themselves, the process cannot be executed earlier in the year.
Although new technology may allow an increase in production capacity, manufacturers have never made more than 300 million doses of flu vaccine in a single year. The slow pace of production means that in the event of an H5N1 flu pandemic millions of people would likely be infected well before vaccines could be distributed.

GLOBAL REACH
The scarcity of flu vaccine, although a serious problem, is actually of little relevance to most of the world. Even if pharmaceutical companies managed to produce enough effective vaccine in time to save some privileged lives in Europe, North America, Japan, and a few other wealthy nations, more than six billion people in developing countries would go unvaccinated. Stockpiles of Tamiflu and other anti-influenza drugs would also do nothing for those six billion, at least 30 percent of whom -- and possibly half -- would likely get infected in such a pandemic.
Resources are so scarce that both wealthy and poor countries would be foolish to count on the generosity of their neighbors during a global outbreak. Were the United States to miraculously overcome its vaccine production problems and produce ample supplies for U.S. citizens, Washington would probably deny the vaccine to neighbors such as Mexico, since governments tend to reserve vaccine supplies for their own citizens during emergencies. Were the United States to falter, it would probably not be able to rely on Canadian or European generosity, as it did just last year. When the United Kingdom suspended the license for the Chiron Corporation's U.K. production facility for flu vaccine due to contamination problems, Canada and Germany bailed the United States out, supplying additional doses until the French company Sanofi Pasteur could manufacture more. Even with this assistance, however, the United States' vaccine needs were not fully met until February 2005 -- the tail end of the flu season.
In the event of a deadly influenza pandemic, it is doubtful that any of the world's wealthy nations would be able to meet the needs of their own citizenry -- much less those of other countries. Domestic vaccine purchasing and distribution schemes currently assume that only the very young, the elderly, and the immunocompromised are at serious risk of dying from the flu. That assumption would have led health leaders in 1918 to vaccinate all of the wrong people. Then, the young and the old fared relatively well, while those aged 20 to 35 -- today typically the lowest priority for vaccination -- suffered the most deaths from the Spanish flu. And so far, H5N1 influenza looks like it could have a similar effect: its human victims have all fallen into age groups that would not be on national vaccine priority lists, and because H5N1 has never circulated among humans before, it is highly conceivable that all ages could be susceptible. Every year, trusting that the flu will kill only the usual risk groups, the United States plans for 185 million vaccine doses. If that guess were wrong -- if all Americans were at risk -- the nation would need at least 300 million doses. That is what the entire world typically produces each year.
There would thus be a global scramble for vaccine. Some governments might well block foreign access to supplies produced on their soil and bar vaccine export. Since little vaccine is actually made in the United States, this could prove a problem for Americans in particular. Facing such limited supplies, the U.S., European, and Japanese governments might give priority to vaccinating heads of state around the world in hopes of limiting social chaos. But who among the elite would be eligible? Would their families be included? How could such a global triage be executed justly?
A similar calculus might be necessary for countries engaged in significant military operations. Troop movements would certainly help spread the disease, just as World War I aided the growth of the 1918-19 Spanish flu. Back then, the flu wreaked havoc on combatant nations. In the summer of 1918, influenza killed far more soldiers than did bombs, bullets, or mustard gas. By October, some 46 percent of the French army was off the field of battle -- ailing, dying, or caring for flu victims. Influenza death tolls among the various military forces generally ranged from 5 to 10 percent, but some segments fared even worse: historian John Barry has reported that 22 percent of the Indian members of the British military died.
In the event of a modern pandemic, the U.S. Department of Defense, with the lessons of World War I in mind, would undoubtedly insist that U.S. troops in Iraq and Afghanistan be given top access to vaccines and antiflu drugs. About 170,000 U.S. forces are currently stationed in Iraq and Afghanistan, while 200,000 more are permanently based elsewhere overseas. All of them would potentially be in danger: in late March, for example, North Korea conceded it was suffering a large-scale H7N1 outbreak -- taking place within miles of some 41,000 U.S. military forces. It is impossible to predict how such a pandemic influenza would affect U.S. operations in Iraq, Afghanistan, Colombia, or any other place.
Armed forces throughout the world would face similar issues. Most would no doubt pressure their governments for preferential access to vaccine and medications. In addition, more than a quarter of some African armies and police forces are HIV positive, perhaps making them especially vulnerable to influenza's lethal impact. Social instability resulting from troop and police losses there would likely be particularly acute.
Such a devastating disease would clearly have profound implications for international relations and the global economy. With death tolls rising, vaccines and drugs in short supply, and the potential for the virus to spread further, governments would feel obliged to take drastic measures that could inhibit travel, limit worldwide trade, and alienate their neighbors. In fact, the Z+ virus has already demonstrated its disruptive potential on a limited scale. In July 2004, for example, when the Z+ strain reemerged in Vietnam after a three-month hiatus, officials in the northern province of Bac Giang charged that Chinese smugglers were selling old and sickly birds in Vietnamese markets -- where more than ten tons of chickens are smuggled daily. Chinese authorities in charge of policing their side of the porous border, more than 1,000 kilometers long, countered that it was impossible to inspect all the shipments. Such conflicts are now limited to the movement of livestock, but if a pandemic develops they could well escalate to a ban on trade and human movement.
Although there is little evidence that isolation measures have ever slowed the spread of influenza -- it is just too contagious -- most governments would likely resort to quarantines in a pandemic crisis. Indeed, on April 1, 2005, President George W. Bush issued an executive order authorizing the use of quarantines inside the United States and permitting the isolation of international visitors suspected of carrying influenza. If one country implements such orders, others will follow suit, bringing legal international travel to a standstill. The SARS (severe acute respiratory syndrome) virus, which was less dangerous than a pandemic flu by several orders of magnitude, virtually shut down Asian travel for three months.
As great as they would be, the economic consequences of travel restrictions, quarantines, and medical care would be well outstripped by productivity losses. In a typical flu season, productivity costs are ten times greater than all other flu-related costs combined. The decline in productivity is usually due directly to worker illness and absenteeism. During a pandemic, productivity losses would be even more disproportionate because entire workplaces -- schools, theaters, and public facilities -- would be shut down to limit human-to-human spread of the virus. Workers' illnesses also would likely be even more severe and last even longer than normal. Frankly, no models of social response to such a pandemic have managed to factor in fully the potential effect on human productivity. It is therefore impossible to reckon accurately the potential global economic impact.

AILING
The potential for a pandemic comes at a time when the world's public health systems are severely taxed and have long been in decline. This is true in both rich and poor countries.
The Bush administration recognized this weakness following the anthrax scare of 2001, which underscored the poor ability of federal and local health agencies to respond to bioterrorism or epidemic threats. Since that year, Congress has approved $3.7 billion to strengthen the nation's public health infrastructure. In 2003, the White House also took several steps to improve the nation's capacity to respond to a flu pandemic: it increased funding for the CDC's flu program by 242 percent, to $41.6 million in 2004; gave the National Institutes of Health an additional 320 percent in funds for flu-related research and development, for a total of $65.9 million; increased spending on the Food and Drug Administration's licensing capacity for flu vaccines and drugs by 173 percent, to $2.6 million; and spent an additional $80 million to create new stockpiles of Tamiflu and other anti-influenza drugs. On August 4, 2004, the Department of Health and Human Services also issued its pandemic flu plan, detailing further steps that would be taken by federal and state agencies in the event of a pandemic. Several other countries have released similar plans of action.
But despite all this, a recent event underscored the United States' tremendous vulnerability. In October 2004, the American College of Pathologists mailed a collection of mystery microbes prepared by a private lab to almost 5,000 labs in 18 countries for them to test as part their recertification. The mailing should have been routine procedure; instead, in March 2005 a Canadian lab discovered that the test kits included a sample of H2N2 flu -- a strain that had killed four million people worldwide in 1957. H2N2 has not been in circulation since 1968, meaning that hundreds of millions of people lack immunity to it. Had any of the samples leaked or been exposed to the environment, the results could have been devastating. On learning of the error, the WHO called for the immediate destruction of all the test kits. Miraculously, none of the virus managed to escape any of the labs.
But the snafu raises serious questions: If billions have been spent to improve laboratory capabilities since 2001, why did nobody notice the H2N2 flu until about six months after the kits had been shipped? Why did a private company possess samples of the virulent flu? Why was the sample included in the kits? In the aftermath of the September 11, 2001, attacks and the anthrax scare, many countries reclassified 1957-58 and 1968-69 influenza strains as Level 3 pathogens, requiring extreme care in their handling, distribution, and storage -- why did the United States still consider H2N2 to be a mere Level 2 pathogen, a type frequently mailed and studied? Finally, around the world, what other labs -- public and private -- currently possess samples of such lethal influenza viruses? The official CDC answer to these questions is, "We don't know."
Even with all of these gaps, probably the greatest weakness that each nation must individually address is the inability of their hospitals to cope with a sudden surge of new patients. Medical cost cutting has resulted in a tremendous reduction in the numbers of staffed hospital beds in the wealthy world, especially in the United States. Even during a normal flu season, hospitals located in popular retirement areas have great difficulty meeting the demand. In a pandemic, it is doubtful that any nation would have adequate medical facilities and personnel to meet the extra need.
National policymakers would be wise to plan now for worst-case scenarios involving quarantines, weakened armed services, and dwindling hospital space and vaccine supplies. But at the end of the day, effectively combating influenza will require multilateral and global mechanisms. Chief among them, of course, is the WHO, which since 1947 has maintained a worldwide network that conducts influenza surveillance. The WHO system oversees laboratories all over the world, chases (and sometimes refutes) rumors of pandemics, pushes for government transparency regarding human and avian flu cases, and acts as an arbiter in negotiations over vaccine production, trade embargoes, and border disputes. Its companion UN agency, the Food and Agriculture Organization (FAO), working closely with the World Organization for Animal Health, monitors flu outbreaks in animal populations and advises governments on culling flocks and herds, cross-border animal trade, animal husbandry and slaughter, and livestock quarantine and vaccination. All of these organizations have published lengthy guidelines on how to respond to a pandemic flu, lists of answers to commonly asked questions, and descriptions of their research priorities -- most of which have been posted on their Web sites.
The efforts of these agencies should be bolstered, both with expertise and dollars. The WHO, for example, has an annual core budget of just $400 million, a tiny increment of which is spent on influenza- and epidemic-response programs. (In comparison, the annual budget of New York City's health department exceeds $1.2 billion.) An unpublished internal study estimates that the agency would require at least another $600 million for its flu program were a pandemic to erupt. It is in every government's interest to give the WHO and the FAO the authority to act as impartial voices during a pandemic, able (theoretically) to assess objectively the epidemic's progress and rapidly evaluate research claims. The WHO in particular must have adequate funding and personnel to serve as an accurate clearinghouse of information about the disease, thereby preventing the spread of false rumors and global panic. No nation can erect a fortress against influenza -- not even the world's wealthiest country.
Few members of the U.S. Congress or its legislative counterparts around the world were alive when the great Spanish flu swept the planet. There may be some who lost parents, aunts, or uncles to the 1918-19 pandemic, and perhaps even more have heard the horror stories that were passed down. But politics breeds shortsightedness, and for decades the threat of an influenza pandemic has been easily forgotten, and therefore ignored at budget time. Politicians and health leaders made many serious errors in 1918-19; some historians say that President Wilson sent 43,000 soldiers to their deaths by forcing them aboard crowded ships to join a war he had already won. But in those days, human beings had no understanding of their influenza foe.
In 1971, the great American public health leader Alexander Langmuir likened flu forecasting to trying to predict the weather, arguing that "as with hurricanes, pandemics can be identified and their probable course projected so that warnings can be issued. Epidemics, however, are more variable [than hurricanes], and the best that can be done is to estimate probabilities."
Since Langmuir's time a quarter of a century ago, weather forecasting has gained a stunning level of precision. And although scientists cannot tell political leaders when an influenza pandemic will occur, researchers today are able to guide policymakers with information and analysis exponentially richer than that which informed the decisions of President Ford and the 1976 Congress. Whether or not this particular H5N1 influenza mutates into a human-to-human pandemic form, the scientific evidence points to the potential that such an event will take place, perhaps soon. Those responsible for foreign policy and national security, the world over, cannot afford to ignore the warning.


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The Lessons of HIV/AIDS
By Laurie Garrett
From Foreign Affairs , July/August 2005

Summary: To get a sense of the broader damage a new pandemic might do, it helps to consider the one the world is currently enduring: HIV/AIDS. Because this deadly scourge moves slowly, many of its social, political, and economic effects have yet to be understood. But the impact is hard to overstate. And it is growing.
Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations. This essay partly results from meetings convened by the council in collaboration with the Joint UN Programme on HIV/AIDS.

SECURITY AT STAKE
If the deadly bird flu discussed in the previous three essays were ever to sweep across the world, the impact on national security would be obvious everywhere. Nations rich and poor would quickly recognize the vulnerabilities of their citizens, economies, public health systems, and armed forces.
But what about the security implications of an existing pandemic, HIV/AIDS, the full impact of which is taking years to be felt? When the disease first struck, few leaders of the hardest-hit countries in sub-Saharan Africa acknowledged the links between HIV/AIDS, social stability, and national security. It took many of them two decades to face facts, and by then HIV/AIDS had spread through their populations and killed large numbers. Nor was such myopia limited to Africa; it was prevalent in developed countries as well. The resulting delays have caused millions of deaths around the world.
Were the Asian bird flu to start infecting humans, the death toll would rise even more quickly. Preparation is therefore critical. Unfortunately, the example of the HIV/AIDS pandemic is not reassuring. Adequate resources for combating the disease have yet to be marshaled, even though the potential for it to cause destabilization has now been recognized at the international level. In 2000, the UN Security Council issued Resolution 1308, warning that the HIV/AIDS pandemic, if unchecked, could threaten world stability and security. Five years after its passage, the resolution will be formally reviewed this July.
AIDS has killed at least 26 million people, orphaning more than 12 million children, and today the virus afflicts 40 million people directly. Although the illness was first officially recognized in the United States in 1981, it has raged in the Great Lakes region of Africa since the 1970s. And yet policymakers still lack sufficient data, computer modeling, and empirical analyses of the disease for effective guidance on prevention and treatment. As a result, the pandemic's impact on economic activity, agricultural practices, childhood development, and the credibility of political leaders is still poorly understood. Too little is known about its effects on businesses in hard-hit countries, which lose upward of three percent of their labor forces to the virus every year. Even less is known about infection rates in most police and armed forces.
Nevertheless, three crucial points have become clear. First, HIV/AIDS is the most complex disease humanity has ever faced and presents it with unprecedented challenges of research and analysis. Second, new threats to stability and security may emerge as the pandemic escalates. Third, a well-conceived campaign to curtail the virus, particularly through development of an effective HIV vaccine, could short-circuit the attendant security concerns. Such a campaign would be achievable. But it has yet to be undertaken.

DEATH IN SLOW MOTION
Unlike the massive pandemics of the past, such as the Black Death or the influenza outbreak of 1918-19, HIV/AIDS inflicts death very slowly. For three decades, the current pandemic has created waves of infection, followed years later by waves of acute disease, and years after that by waves of death and family disruption. In the prior two megaplagues, the periods between infection, illness, and death and family disruption were days to weeks. Entire societies experienced the shock simultaneously, grieved in unison, and witnessed the impact on the society and state as one.
In the case of HIV/AIDS, however, the intervals between these waves have lasted up to 14 years, and the waves themselves have been staggered, with the progression of infection and illness varying from person to person and region to region. Successive high-amplitude waves have swept over sub-Saharan Africa for up to four human generations. On the other hand, low-amplitude waves have gone almost unnoticed for ten years or more in India, Indonesia, Russia, Southeast Asia, and Ukraine. Only now are these areas experiencing large-scale infection. Illness, death, and the mass creation of orphans are still ahead.
Even within Africa, the timing of HIV/AIDS and its impact have varied. The Great Lakes region has been suffering for 35 years now, long enough that every facet of society there has been reshaped. On the other hand, Botswana, Malawi, Swaziland, and most of western Africa are now in a third generation of low-amplitude waves. South Africa, Namibia, and Angola have yet to experience the full death tolls of their first, rapidly rising wave of infection.
Around the world, affected societies have begun to adapt to the changes wrought by AIDS to varying degrees: extended families have started absorbing orphans, communities have begun altering farming practices, and governments have started increasing their health spending. Thailand, for example, has successfully adopted effective containment measures (such as massive condom distribution and public education) that have brought the epidemic under a remarkable degree of control, both in the country's military and its civilian population. Uganda, conversely, may be backsliding after what seemed like early progress against the disease. Ugandan scientists warn that the apparent downward trend in HIV/AIDS there may merely be a hiatus in the epidemic, caused not by an effective AIDS-control campaign but by the wholesale death of the infected adult population; April 2005 data show that adult infection rates are indeed climbing. If these analysts are correct, Uganda could experience yet another round of infection, disease, and death when today's youth become sexually active adults.
The long shock waves caused by AIDS, moreover, are washing over many countries that are simultaneously being swamped by other diseases -- malaria, tuberculosis, childhood dysentery, gonorrhea, antibiotic-resistant bacterial infections, and newly emerging infections such as severe acute respiratory syndrome (SARS) and the Marburg virus. Many of these countries also suffer from other problems that impede economic development and cause social disruption, such as military conflict and social unrest. It is therefore extremely difficult to predict how HIV/AIDS will affect these states and their societies, economies, cultures, and politics. The full impact may not be known for a generation, and the results will vary around the planet. The Joint UN Programme on HIV/AIDS and the Shell Corporation have attempted to model the pandemic's future, and their forecasts are gloomy. And even these predictions depend on government actions that may not be taken.
Politicians are usually shortsighted, and those making HIV/AIDS policy have proved to be no exception. To date, no HIV/AIDS policy enacted by any government or by the UN addresses more than one HIV/AIDS wave's worth of activity, and most epidemic policies have only been implemented in reaction to specific instances of public outcry. Few political leaders and officials recognize that current anti-HIV/AIDS drugs are not curative and, to fend off death, must be taken daily for the rest of a patient's life. The World Health Organization, in a program funded by rich nations, intends by year's end to equip a modest three million people in poor countries with antiretroviral drugs. But to be effective, the program must last for many years rather than be a one-time expense. If wealthy donors cut off their assistance, few poor countries will be able to pick up the treatment costs on their own. A massive wave of death would ensue, as the rich world turned off the life support system of all three million people.

MILITARY MATTERS
When assessing the effects of HIV/AIDS on most military and police forces, two factors stand out. First, infection among uniformed personnel has risen sharply. Second, the rate of infection in most countries' forces is at least as high as it is among their civilians. In Russia, the HIV/AIDS rate among potential 18-year-old draftees has shot up 25-fold since 1999. The annual new infection rate for HIV in Russia's military forces has also risen sharply, climbing from about 0.1 cases per 100,000 soldiers in 1995 to nearly 40 per 100,000 in 2003. In both 2002 and 2003, about 5,000 conscripts -- or about a third of all young men drafted -- were rejected for military service for health reasons that included, chiefly, HIV/AIDS, tuberculosis, drug addiction, and "psychological problems."
Murray Feshbach, a noted demographer at the Woodrow Wilson International Center for Scholars, has written that Russia will find it increasingly difficult to staff its army as illness claims more of its youth and its overall population shrinks. Feshbach sees similar trends in the armed forces of Ukraine, the Baltic states, and possibly Belarus and Moldova as well. The HIV/AIDS and tuberculosis epidemics in these countries are spiraling out of control, probably growing faster than anywhere else in the world.
This is not to say that HIV infection among police and armed forces elsewhere is not also a grave problem. Troop strength in Malawi, for example, has already reportedly fallen to 50 percent of the minimum capacity needed to guarantee state security. In 2004, the Zimbabwe Ministry of Defense admitted that the military's HIV infection rate was about 3 percent higher than that of Zimbabwe's civilian society, which was then just above 26 percent. In Mozambique, police recruits cannot be trained fast enough to replace those dying of AIDS. High HIV infection rates have impeded South Africa's attempts to transform its previously all-white military command into one that more closely mirrors South African society. In Ethiopia, a 2004 test of police officers' wives found that nearly a third of them were HIV positive. Nothing is publicly known about the HIV rates within the world's two largest military forces: China's 2.5 million-strong People's Liberation Army, and India's 1.33 million-member defense forces. Nor is much known about the levels of infection in the rest of Asia's military and police forces. In May, however, India's minister of defense stated that AIDS was the fifth-leading cause of death for his nation's armed forces.
Dead recruits and infantry troops tend to be easy to replace. A general or top technical officer, however, often represents decades of training and acquired experience. Around the world, many militaries are quietly putting their infected commanders on antiretroviral medicines, in hopes of buying time to train their replacements. U.S. military experience reveals the wisdom of this move, as HIV/AIDS-related death rates among infected U.S. armed forces plummeted from 40 percent during the period from 1985 to 2001 to just 1.4 percent since 2001, thanks largely to such treatment. Brazil's experience, however, offers a stark counterpoint. Brazil, like the United States, has also used antiretroviral drugs to treat the estimated one percent of its uniformed personnel who are HIV positive. But the Brazilian officers and enlisted men treated have grown steadily more resistant to the drugs, with some 86 percent of affected personnel now reporting resistance to at least one of the powerful protease-inhibitor drugs used to hold the virus at bay.
There are four essential conclusions that can be drawn from the available information about HIV infection among military and police forces. First, in hard-hit parts of the world, these individuals, who are the protectors of stability and security, are increasingly falling victim to AIDS -- as much or more so than the general adult population. As death claims ever more citizens, it will also claim more troops, posing serious problems for law and order a decade from now.
Second, in some areas with high infection rates, especially in the former Soviet Union, militaries and police are finding it hard to identify healthy recruits to replace the ranks of their aging and HIV-infected forces. Third, while many uniformed services are supplying antiretroviral drugs to their command officers in the hope of prolonging their lives, providing these drugs solely to the upper echelons may eventually undermine morale among the rank and file, even leading to mutinies. Such special treatment may also undermine the moral authority of the police and the military among the general population. And even the life-prolonging wonders of antiretroviral drugs may be short-lived, due to the emergence of drug-resistant strains of HIV.
The HIV/AIDS pandemic is also having a major impact on UN peacekeepers. All military personnel stationed with UN operations are by regulation encouraged to undergo voluntary HIV screening. In addition, the UN's roughly 47,000 peacekeepers all receive training about the risks of AIDS, other sexually transmitted diseases, and appropriate behavior with civilian personnel. They also all get a plastic "HIV/AIDS Awareness Card for Peacekeeping Operations" and five or six condoms a week during foreign deployment. Most of the 65,000 peacekeepers perform their work with noble courage and free of HIV risk.
Nevertheless, the UN has recently been rocked by sex-related scandals among peacekeepers in the Democratic Republic of the Congo and elsewhere, and several studies show that troops stationed away from their home countries are at significant risk for acquiring HIV. A Nigerian military survey, for example, has found that the infection rate among soldiers who are based near their wives and homes mirrors that of society at large -- about five percent. But rates among those deployed for peacekeeping operations in Sierra Leone, Liberia, and Côte d'Ivoire are up to three times higher. Nigeria has witnessed a stark increase in noncombat mortality in its military ranks over the last five years, with 43 percent of that surge directly ascribed to HIV.
One counterintuitive effect of warfare, as the recent histories of Angola, Cambodia, Ethiopia, Namibia, Nigeria, South Africa, and Zimbabwe show, is that it can actually reduce the risk of HIV infection. During wartime, civilians either hunker down in their homes or flee war-torn regions and become refugees. Trade grinds to a halt, borders are locked tight, and social mobility is minimized.
Consider Angola, for example. For 27 years, it was wracked by a civil war that left the now-peaceful nation in shambles. War, however, largely kept HIV outside Angola, since most forms of trade and travel, both within the country and across its borders, were essentially shut down for three decades. Since the end of the conflict in 2002, Angola's borders have reopened. Peace has brought greater trade -- but also an increased HIV infection rate.
One critical and horrifying exception to the general dampening effect of warfare on the rate of HIV infection occurs when rape is used as a weapon. A recent study of women who were raped during the 1994 Rwanda genocide shows that today nearly 80 percent of them are HIV positive. Similarly, a survey of pregnant women in parts of northern Uganda where the rebel paramilitary group the Lord's Resistance Army has committed atrocities, including rapes, for two decades finds that female infection rates are double those in the rest of Uganda. About half of the rape victims who survived the Sierra Leone civil war are also infected.

ON THE TRAIL OF THE DISEASE
DNA fingerprinting is proving to be a vital tool in pinpointing how various HIV strains and clades (subgroups) move around the world. Using DNA testing, researchers have proved that the rapidly growing HIV/AIDS epidemic in the former Soviet Union comes from a new strain and is being spread by an infection method -- narcotics injection -- that minimizes the mutation of the virus as it passes from one victim to another. As this evidence suggests, the HIV/AIDS epidemic in the former Soviet Union may well pose security threats to the region, but it is a domestic phenomenon and cannot be ascribed to outside forces.
In contrast, molecular evidence paints a very different picture for Asia, where several different clades (and unique recombinations of those clades) are now circulating in the area that spans from eastern India to southern Vietnam. Several research teams have proved that these various HIV clades can be tracked along four major routes, all originating in Myanmar. One type can be traced to a route that runs from the forest regions of eastern Myanmar into Yunnan, China. A second strain has followed the same route, and then continued up to Xinjiang, China. A third runs through Laos, into northern Vietnam, and then into Guangxi, China. And a fourth travels from western Myanmar to Manipur, India.
Surveys conducted at significant risk inside Myanmar -- a weak state governed by a corrupt junta; riven by civil war; beset by rival gangs of drug, gem, and sex-slave smugglers; and one of the world's top opium producers -- show that the various types of HIV are concentrated in key population groups in the country. The highest infection rates are found among prostitutes, who account for about half of all those infected, and among heroin users, who suffer from infection rates as high as 77 percent in the country's north. HIV cases and specific HIV subtypes cluster in poppy-growing regions and then travel along heroin-smuggling routes across Asia. This evidence suggests that Myanmar may be the greatest contributor of new types of HIV in the world. In fact, there has been only one outbreak of HIV in Central Asia that seems to have originated anywhere else.
Africa's epidemic is much more difficult to track genetically than Asia's because it is much older and involves enormously diverse strains of the pathogen. Most perplexing is the situation in Congo, where war has raged for years, engaging military forces from all over the continent and peacekeepers from all over the world. Scientists find the area too dangerous to work in, making it almost impossible to gather samples of the HIV strains there. What evidence is available, however, suggests that Congo has become a mixing pot for HIV, with dozens of unique forms of the virus circulating in the vast nation.
As the case of Congo illustrates, the use of genetics as a form of verification or to track the spread of HIV is currently limited by the way blood samples are collected. Most sampling around the world is performed by scientists seeking to answer questions unrelated to HIV, and genetic studies on those samples are usually conducted by still another group of experts. Funding should be made available to support the targeted collection and analysis of samples. Scientists engaged in such efforts would need protection, such as that currently provided for UN weapons inspectors, as the regions most likely responsible for promulgating and spreading new forms of HIV tend to be among the world's most dangerous.
Funding such efforts would have an enormous benefit: it would help scientists understand the overall evolution of HIV. The virus mutates at a very high rate, and since its appearance in human beings several decades ago, HIV has burst out into many genetic branches. At the moment, no scientist can say where this evolution is headed or what new attributes the virus might one day acquire. Studying the virus' evolution could help answer those questions.

AIDS AND POLITICS
The most obvious political dimension of the security threat caused by HIV/AIDS is the risk that it will claim the lives of national leaders, as parliamentarians, cabinet members, ministers, and the military become infected and die. Until now, such deaths have generally gone unacknowledged: the deceased are listed as victims of tuberculosis, "prolonged illness," or other less stigmatizing problems. To date, the death of not one head of state has officially been designated an AIDS death. Nevertheless, the illness has taken its toll, depriving many nations of seasoned leaders and institutional experience. For example, between 1964 and 1984, Zambia held 14 by-elections to replace incumbents who had died in office. In 1984, the country officially acknowledged its first AIDS case, and between that time and 2003, the number of by-elections soared to 102. Of this total, 29 were due to the death of the incumbent. Each of these special elections represented a loss of political experience and came at enormous monetary expense to the government. The Institute for Democracy in South Africa has published long lists of similar figures for countries all over sub-Saharan Africa.
The ranks of Africa's civil servants are also being thinned by the pandemic, rendering some previously weak bureaucracies only marginally functional. In areas with the highest HIV infection rates, even those government workers who survive often miss work due to the exigencies of caring for relatives or rearing the children of deceased family members. The UN AIDS program has documented the steady erosion of key civil-service sectors in sub-Saharan Africa. Teachers, hospital workers, and financial-sector employees have been the hardest hit.
As serious as these problems are, the most profound challenge to state stability caused by HIV/AIDS will be the death toll among men and women aged 20-50 years, who are workers, parents, leaders, and trained professionals. Already, AIDS is distorting the populations of some countries, where the older, dependent population remains comparatively intact and children and adolescents are coming to radically outnumber adults. Throughout much of sub-Saharan Africa, life expectancy has dropped precipitously.
Nicholas Eberstadt, of the American Enterprise Institute, argues that declining life expectancy constitutes the single most important threat to the security of hard-hit countries, as it will lead to diminishing state capacity. According to the U.S. Census Bureau, 40 nations will have declining life expectancies by 2010, and in 35 of them, HIV/AIDS will be the primary cause (25 of these countries are in sub-Saharan Africa). Eight Caribbean nations and seven former Soviet states will also see their life expectancies drop compared to 1990 levels, and some of the declines will be due to HIV/AIDS. It may not always be possible to tease out the impact of AIDS from the toll inflicted by its frequent companions, such as tuberculosis, malaria, and poverty. But it is noteworthy that the key reversals in life expectancy seen in Africa started between 1985 and 1990, when the first great wave of AIDS deaths swept through the region. In Malawi, by 2000 life expectancy had fallen to the country's 1969 level, essentially reversing 30 years of development investment. Life expectancy in Botswana dropped by 30 years between 1990 and 2002 -- a decline that is unprecedented in known human history.
Most of the countries now hit hardest by HIV/AIDS already had "youth bulges" before the virus arrived, meaning that a disproportionate percentage of their populations were under 29 years of age. HIV/AIDS is now exaggerating these bulges, with the greatest percentage increases appearing in the adolescent population. In 1975, only 17 countries in the world had youth bulges so severe that more than half of their population fell in the 15-29 age bracket. Today, 37 countries belong to that category, nearly all of them in sub-Saharan Africa. Several studies show that countries that had such radically large youth bulges in the period between 1990 and 2000 were three times more likely to suffer civil wars, coups, or armed insurrections.
In general, the presence of three key population problems in a given country indicate a likelihood of instability: a youth bulge, rapidly rising population concentrations in underdeveloped cities, and poor crop or fresh-water production. Fortunately, in many countries, all three of these factors are subsiding, thanks to economic improvements and the strengthening of civil society. But in the poorest parts of the world, they are becoming increasingly pronounced, with dangerous consequences.
That HIV/AIDS is hitting hardest precisely those areas most afflicted by dire poverty may make it impossible to observe direct disease impacts on most local and regional economies. Nevertheless, the pandemic is pouring salt on economic wounds and exacerbating already widening chasms in wealth and food security, and this process will only get worse in the future. The presence of HIV/AIDS also dissuades outside investment, as few companies are interested in building operations in a region where labor productivity and costs are so dramatically affected by disease and death.

RICH VERSUS POOR
Widening gaps in access to anti-HIV drugs are creating glaring differences between the life expectancies of infected Americans and victims in the rest of the world. Resentment is building in both middle-income and poor nations, as the wealthiest nine countries become gerontocracies, while the poorest nations witness the evaporation of previous development gains, rising foreign debts, and increased mortality rates.
In his 2002 State of the Union address, President George W. Bush called for a $15 billion program to combat HIV/AIDS, largely on a bilateral basis, in 14 countries. Known as PEPFAR (the President's Emergency Plan for AIDS Relief), the program eventually added a 15th country (Vietnam) to its list of targets. As of March 2005, PEPFAR had spent only three percent of its funds, providing treatment to 155,000 people worldwide. The program plans to treat 200,000 people by June 2005. PEPFAR has also provided supportive (that is, nonmedical) care to 1.7 million people affected by the epidemic, including 630,000 orphans. As currently conceived, PEPFAR will treat 2 million people by the end of 2008 and provide other types of care to another 10 million. No other nation has mounted an HIV/AIDS campaign of this scale, though many have contributed to the UN's Global Fund to Fight AIDS, Tuberculosis, and Malaria, which sponsors treatment and prevention campaigns worldwide that rival the scale of the U.S. effort.
In 2004, the appropriations bill allocating money for PEPFAR stipulated that a third of the prevention and education funds had to be spent on abstinence-promoting programs, that none of the money could be spent buying sterile syringes or needles for intravenous drug users, and that faith-based organizations should receive special priority in the receipt of care and treatment funds. A more recent White House stipulation has required recipient countries and organizations to denounce prostitution. All of these restrictions have proved enormously controversial, both inside the United States and overseas. Brazil, for example, recently rejected U.S. support on the grounds that it would not be possible to promote safer sexual practices among prostitutes and their clients while morally castigating them. As a result of such strictures, PEPFAR is hardly winning many hearts and minds. Perceptions will likely improve, however, if Congress continues funding the program and U.S.-backed treatment becomes far more available and visible.

AIDS PAST AND FUTURE
Trying to imagine the future shape of the HIV/AIDS pandemic, some two or three waves ahead, is exceedingly difficult. Were the global community now engaged in a highly motivated, multibillion-dollar campaign involving ever more tools (including condoms) in the public health kit, coupled with a Manhattan Project-scale effort to discover and develop an effective HIV vaccine, there might be some cause for optimism. But no such programs exist. If no effective vaccine or cure is found within the next 20 years, areas of the world that are now witnessing explosive epidemics or are in their second or third wave of HIV infection may well find themselves harder hit -- and more deeply transformed -- than Europe was by the Black Death. Many of Africa's characteristics today mirror those of preplague Europe, including an enormous surplus of unskilled labor, a lack of clear property rights for the bulk of the population, domination by tiny elites, widespread warfare waged both by state and mercenary forces, and a transition under way from dispersed agrarian to disastrously urbanized societies. Each of these economic, political, and social characteristics of early fourteenth-century Europe was turned upside down by the Black Death. There is no reason to imagine that Africa's modern plague will have any less of an impact, albeit in slow motion.
The introduction of treatment options for HIV/AIDS could both mitigate and exacerbate the changes. Using antiretroviral therapy to treat key leaders and sectors of society -- including armed forces -- will stretch out the intervals between waves of the pandemic in those select populations. This delay will, in turn, give governments a better chance to cope, both at the national and local levels. But inequitable access to medicine is already creating global tension, as governments in poor countries become angry that they cannot afford to give their people life-sparing drugs that are readily available in wealthy countries. If poor and middle-income countries start using external funds to provide life-extending medicines to their elites, they risk creating the same tensions domestically. On the other hand, the survival of certain states may literally depend on their leaders (including military commanders, top politicians, physicians, teachers, and important bureaucrats) getting access to the medicines.
For donor states the best option is to bite the bullet and spend heavily not only on HIV/AIDS prevention, care, and treatment, but also on development aimed at bringing the poor world into the global economy, so that it may eventually derive sufficient wealth to pay for the great expenses involved with coping with HIV/AIDS.
Given the risks to armed forces, police, and UN peacekeepers, international programs aimed at preventing high-risk sexual activities and drug use, as well as those that provide condoms and sterile needles, should be bolstered and financially supported by wealthy nations.
Viral genetic fingerprinting should be used to trace the spread of HIV and identify key national or transnational forces (such as heroin smuggling) associated with its spread. Global security may require spotting dangerous new evolutionary trends in the virus.
The paucity of reliable data regarding the current effects of pandemics on economic and social issues remains a serious concern. Major scientific institutions in North America, Europe, and Japan should fund and promote such science, conducted in collaboration with researchers from hard-hit regions. Longitudinal cohort studies should be created now to track over the coming decades key population groups, such as children orphaned by AIDS, agricultural workers, soldiers, peacekeepers, migrant workers, and miners.
It bears repeating that were extremely aggressive prevention and vaccine research efforts executed and well funded today, they could render the security concerns of tomorrow moot. Sadly, such funding has not been forthcoming. In 2004, total global spending on HIV vaccine development, public and private, was $680 million, $526 million of which came from the U.S. government and $70 million of which came from private corporations and charities. That amounted to just one percent of total spending on HIV-related programs.
In the aftermath of September 11, 2001, the United States tends to define all national security concerns through the prism of terrorism. That framework is overly limited even for the United States, and an absurdly narrow template to apply to the security of most other countries. The HIV/AIDS pandemic is aggravating a laundry list of underlying tensions in developing, declining, and failed states. As the burden of death due to HIV/AIDS skyrockets around the world over the next five to ten years, the disease may well play a more profound role on the security stage of many nations, and present the wealthy world with a challenge the likes of which it has never experienced. How countries, rich and poor, frame HIV/AIDS within their national security debates today may well determine how well they respond to the massive grief, demographic destruction, and security threats that the pandemic will present tomorrow.


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Laurie Garrett paper 1

Missed Opportunities
Governance of Global Infectious Diseases
From International Health, Vol. 27 (1) - Spring 2005
Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations.
Scott Rosenstein is a research associate at the Council on Foreign Relations.
Addressing the UN General Assembly Special Session on HIV/AIDS in June 2001, UN Secretary-General Kofi Annan declared, “For there to be any hope of success in the fight against HIV/AIDS, the world must join together in a great global alliance.” Earlier, in September 1995, US President Bill Clinton’s Committee on International Science, Engineering, and Technology designated infectious disease as a threat to national security. By the turn of the century it seemed possible that years of neglecting the surging HIV pandemic and other lethal infectious diseases might be reversed. Large-scale initiatives from multilateral agencies, deep-pocketed foundations, and the US government infused hope into an area that has historically been underfunded and overshadowed.
But today the optimism is dangerously close to slipping away. Now that real money is on the table, the entire global health effort seems to be descending into bureaucratic and economic quicksand similar to that which has trapped other international development programs for decades. Programs are competing with each other, and key donors are shying away from the multilateral Global Fund in favor of bilateral programs. Implementation of the World Health Organization’s (WHO) program to put three million people on life-saving HIV/AIDS treatment by 2005 is proving staggeringly difficult and demoralizing for much of the WHO staff. US President George W. Bush’s Emergency Plan for AIDS Relief (PEPFAR) has become so highly politicized that its achievements are obscured by controversy. Similarly, the Global Fund has become a lightning rod for debate regarding nearly every aspect of public health funding and implementation. Tuberculosis experts, having long struggled to implement so-called Directly Observed Therapy using very cheap drugs for only months per patient, now shake their heads and say, “I told you so: the drugs are not the issue; it is the infrastructure.”
The approaches and effectiveness of the major players in the global health arena must be reexamined. As these efforts move forward, new avenues of communication and cooperation must be established to mitigate current obstacles while capitalizing on new opportunities.
The Problem
It will never be possible to create a disease-free world or to eliminate the potential for the emergence of new deadly microbes. Policies aimed at such goals will always fail. For example, scientists now understand that the Ebola virus is an ancient organism that has for centuries infected isolated individuals in central Africa. That cannot be stopped. But scientists also understand that Ebola epidemics have occurred when individuals infected with the virus entered desperately poor hospitals, where dearths of sterilizing equipment and basic protective gear conspired to offer the virus spectacular opportunities for transmission. Inadequately supplied hospitals act as disease amplifiers, giving the isolated infection opportunity to become a full-blown epidemic.
With very few exceptions, the disease amplifiers in the world today are manmade and therefore humanly controllable. Within health systems, they include lack of infection control in hospitals, reuse of syringes, and unscreened blood supplies. More broadly, exotic animal markets, unclean urban water supplies, lack of proper sewage systems, and unstable, conflict-ridden environments provide excellent breeding grounds for infectious diseases to spread and wreak havoc on already vulnerable populations. Yet it would be shortsighted to think of infectious disease as a problem for solely the poor and powerless. These diseases do not discriminate; they are undeterred by state borders, party affiliation, or socioeconomic status. With air travel and human migration on the rise, so too is the possibility that deadly microbes can and will circumnavigate the globe with speed and precision.
Global health investment is therefore an issue not only for do-gooders. A self-interest component to the global health debate has clearly emerged—thankfully, because purely altruistic efforts often fall short of international support and sustainability. The interconnected nature of the world makes ignorance of issues such as deadly infectious diseases not only immoral, but self-destructive. This argument is neither new nor unique. However, for much of the last century, the health community scrambled to get access to small amounts of funding to prevent and treat malaria, tuberculosis, HIV/AIDS, vaccine-preventable illnesses, and a host of other killers, even as leaders in the wealthy world declared microbial threats were, from their standpoint, conquered. It has long been argued that detailed, multilateral global surveillance efforts are imperative to stem the global spread of deadly diseases. But when epidemics of Ebola, nipah, hantavirus, and other deadly diseases broke out in the early and middle 1990s, WHO and the US Centers for Disease Control (CDC) had to go begging for funds for scientists’ plane tickets and laboratory supplies. Disease surveillance was haphazard at best.
It would be impossible to reverse the rising death toll of HIV/AIDS without attacking its partner diseases, most significantly tuberculosis. HIV-weakened immune systems make individuals more susceptible to tuberculosis. WHO estimated in 2004 that tuberculosis accounted for approximately 13 percent of AIDS deaths worldwide. “The world has made defeating AIDS a top priority. This is a blessing. But tuberculosis remains ignored,” warned former South African President Nelson Mandela at the 2004 Bangkok AIDS meeting. The window of opportunity to control tuberculosis is closing as drug-resistant forms of the bacterium emerge all over the world. We now have drugs that can cure non-resistant forms of tuberculosis infection for as little as US$10 per patient in developing countries. Yet, Mandela noted, a very simple and inexpensive strategy for control and cure of tuberculosis has been failing in much of the world, pilloried by funding shortfalls and desperately inadequate health infrastructures.
Lack of funding and infrastructure has, in turn, created human resource shortfalls that have nearly crippled the capabilities of institutions endeavoring to create sustainable programs that can be administered with local participation and ownership. A “brain drain”—or, better put, “talent drain”—is removing health professionals from already understaffed programs and countries. A 2004 report from the Joint Learning Initiative, a research group of more than 100 global health scholars and practitioners, estimated that Africa needs approximately one million more health care workers to deliver adequate care to its people. The report draws attention to the massive flow of experienced health care workers in developing countries who are leaving their homelands to find better paying jobs in the developed world—where health care workers are also in short supply.
To the Rescue?
With a mix of volunteerism, elbow grease, and paltry funds, public health advocates the world over did their level best to hold back the rising gap in life expectancy between rich and poor nations and control infectious disease outbreaks. Slowly, recognition began to build and key decision-makers began to see the value in tackling several pressing global health issues.
Under the leadership of economist Jeffrey Sachs, a team of economists and scientists pulled together an historic Macroeconomics of Health report, not only calculating the costs of dozens of infectious diseases, but also putting price tags on their prevention and treatment. The Clinton Foundation and Doctors Without Borders successfully negotiated prices for Highly Active Antiretroviral Therapy (HAART) for HIV/AIDS patients from generic manufacturers down to the point where it seemed possible to treat an HIV/AIDS patient for less than US$200 per year. Patent drug manufacturers responded by bringing down the prices of their drugs as well. To support this effort, more than 100 of the world’s most powerful corporations combined forces, creating the Global Business Coalition to fight HIV/AIDS. The Bill and Melinda Gates Foundation alone has committed hundreds of millions of dollars towards health interventions around the world.
In 2001, after Annan’s call for between US$7 and US$10 billion annually to address selected infectious diseases and the Group of Eight leaders’ in-principle endorsement of those funding levels, there was a noticeable shift. The Global Fund to Fight AIDS, Malaria, and Tuberculosis was created, offering an independent, accountable mechanism for funneling money from the wealthy world to the poor. The Global Fund was envisioned as an institution that could capitalize on the capabilities of both the private and the public sector to overcome the drawbacks of both. On the heels of the establishment of the Global Fund, WHO Director General Lee Jong-Wook ostensibly staked his new leadership of WHO on “3x5,” a campaign to get HAART to three million people in poor countries before the end of 2005.
For much of its existence, the World Bank took the position that economic development would naturally create improvements in health but rejected the converse notion that investment in the health sector would produce economic gains for the developing world. The World Bank had a change of heart regarding investment in the health sector: it recently began implementing its Multi-country HIV/AIDS Program for Africa and has become the largest overall funder of health-related programs in the developing world.
In 2002 the Bush Administration decided to pursue a program, PEPFAR, to combat AIDS largely on a bilateral basis in 14 countries. PEPFAR eventually added a 15th country, Vietnam, to its list of African and Caribbean nations. Its target is treatment of 200,000 people by June 2005.
The Results
Despite all these efforts, more people died of tuberculosis, malaria, and HIV/AIDS in 2003 than in any year in history. Drug resistance threatens the 20th century’s successes in battling a range of bacterial and parasitic diseases. Combined, these killers are continuing to reshape societies, producing dramatic demographic changes that threaten local, regional, and global stability. To be sure, it is still early for many of these initiatives. But the prognosis is not improving.
From a programmatic standpoint, many of the current infectious disease treatment and prevention efforts appear very narrow in focus, failing to consider the interconnected nature of these diseases. Tackling only HIV/AIDS without proper attention to tuberculosis means ignoring the number-one cause of HIV/AIDS-related death and allowing continued community spread of tuberculosis. Creating stand-alone HIV/AIDS clinics risks further stigmatizing individuals who visit these clinics, especially in societies that do not discuss HIV/AIDS openly and shun those known to be HIV-positive. It seems the exceptionalism of the international community’s approach to HIV/AIDS may ultimately reduce its likelihood for success and community acceptance.
Worse, there is a glaring lack of available institutional mechanisms capable of organizing and executing the ambitious programs currently being proposed or underway. The result is consistent interagency conflict: agencies are often either repeating others’ work or competing for resources. Health programs are fighting over poor countries’ dwindling pools of health professionals, bogus generic drug makers are knowingly selling poor products, ministries of health are sitting on, or siphoning off, millions of dollars in unspent donor funds for vital programs. Fighting over what remains an inadequate pool of funds for all has led many leaders and donors to complain that too much money is going to one health drive over another. Questions of patent rights versus generics, abstinence versus condoms, treatment versus prevention, faith-based versus secular initiatives, research versus implementation, and a host of other false dichotomies have overwhelmed these health debates.
In poor countries, the sudden plethora of health programs has spawned a seemingly endless stream of donor-mandated forms and a similarly large number of studies to conduct in order to demonstrate implementation and offer accountability. Simply keeping track of the demands of divergent benefactors requires the time and professional skills of a small army of English-speaking paper-pushers. The campaign to treat HIV-positive people with HAART threatens to devour the health talent of entire nations, undermining everything from child immunization programs to control of other sexually transmitted diseases.
Even with the influx of money into global health, key institutions are still struggling to make ends meet. WHO, with a core program budget just exceeding US$400 million, suffers from chronic under-funding. The institution is also suffering from an identity crisis as it struggles to continue providing technical oversight while rolling out its own ambitious large-scale projects such as the 3x5 program. The strain of this dual responsibility is beginning to show. WHO officials reported that the program was “just short” of the July 2004 treatment goal of 500,000, laying claim to all the estimated 440,000 people in the poor world now on the drugs. The likelihood that they will meet their target of three million people on antiretrovirals by the end of 2005 appears to be dwindling. Failure would be a substantial setback that could threaten donor and government confidence levels in WHO and current HIV/AIDS efforts in general.
The Global Fund also finds itself unable to meet its fiscal responsibilities. It has fallen far short of the US$8 billion donation requirements recommended by the WHO Commission on Macroeconomics and Health. To date, the Global Fund has committed only about US$900 million for its next round of grants to poor countries and nongovernmental organizations, though it has received more than US$3.6 billion in applications deemed scientifically sound. Disbursement delays have also hamstrung this fledgling organization. In a 2004 study by Ruairí Brugha and others in the Lancet, all four of the countries surveyed in sub-Saharan Africa cited as one of their main concerns “delayed disbursement of funds and difficulties in managing evolving Global Fund processes.” They also noted that “high expectations of rapid funding, when grant approval the previous year had received much national media attention, led to a crisis of expectation.”
Part of this funding shortfall can be attributed to the wealthy world’s lack of commitment. EU countries, as well as the United States, have failed to meet their responsibilities to the Fund. The Bush Administration argues that it has given more money to the Fund than any other country—US$683 million since 2001—and has indicated willingness to give more so long as the United States does not donate more than one-third of all contributions in a given year. In contrasting US contributions to the Fund with those of other nations, the US Department of Health and Human Services recently insisted that a US twelve-month fiscal year’s worth of donating be compared with just nine calendar-year months’ worth of EU contributions, drawing the ire of Europeans.
The United States prefers to focus on its own bilateral HIV/AIDS programs. As currently conceived, PEPFAR will treat two million people and provide other types of care to ten million by the end of 2008. As of September 2004, PEPFAR has actually spent 1.2 percent of its funds, directly providing treatment to 18,800 people.
For much of its existence, PEPFAR has been mired in fights over whether its dollars could be spent buying cheap generic drugs versus US-patented products, over condom promotion versus abstinence, and over how best to mete out funds through a laundry list of competing federal agencies (among them the CDC, the US Agency for International Development (USAID), the National Institutes of Health, and the Department of Defense). In a sense, PEPFAR is a global treatment access entitlement program. To the degree the United States continues to go it alone, the burden for maintaining the health of hundreds of thousands of people around the world will rest on US taxpayers for years, quite possibly decades, to come—a burden born, moreover, by a US populace that is decreasingly likely to have health insurance or be able to afford medications for itself. The foreign policy implications of stopping funding—in essence, committing medical murder—are obviously profound.
Congressional whims aside, should there be regime change in a recipient country, the United States would face a critical moral and political dilemma. The appropriations bill allocating FY2004 PEPFAR money stipulated that a third of prevention and education funds had to be spent on abstinence-promoting programs, none of the money could buy sterile syringes or needles for IV drug users, and faith-based organizations should receive special priority for receipt of treatment funds. Any organization or US program thought to promote access to abortions, or to chiefly promote birth control and condom use, has lost US government funding and support. In Uganda, for instance, the government claims HIV “prevalence” dropped from 30 percent in 1990 to 5 percent today. President Yuweri Museveni, signaling his allegiance to the Bush Administration, told the 2004 International AIDS Conference that the key to success was a campaign that pushed abstinence before marriage and fidelity after marriage. That no doubt helped, but the country’s only long-term study shows the number of new infections in southern Uganda dropped by about 40 percent between 1990 and 2002 without any significant changes in general sexual behavior. The only factor that changed, according to the study, was the increase to an 80 percent rate of condom use between casual sex partners.
Even the US Congressional General Accounting Office’s recently released report cites the Bush Administration’s programmatic restraints as an obstacle to PEPFAR’s success. Politicians may not like the idea of handing out sterile needles to heroin users, for example, but such a program in New York City pushed HIV among drug injectors down from a 1990 high of 50 percent to 15 percent in 2002.
Though PEPFAR funds are meant also to address tuberculosis and malaria, USAID cannot explain how it spends most of its tuberculosis and malaria money. In September 2004 testimony to the House Committee on International Relations, USAID representatives indicated US$65 million was spent in FY2003 for malaria efforts but could specify only US$4.2 million in purchases of anti-malaria bednets. The remainder was unaccounted for.
All the while, new infectious diseases, such as Severe Acute Respiratory Syndrome (SARS) and “Mad Cow,” continue to surface. Globalization ensures many more microbial surprises lurk in the future. The emergence of humanly transmissible strains of avian influenza, or “bird flu,” poses the very real possibility of a 1918-type flu pandemic, which killed between 20 and 50 million people in 18 months, including nearly 700,000 in the United States, and circumnavigated the globe in four months, infecting one-fifth of the global population. Although pharmaceutical improvements in treatment and vaccine possibilities offer hope that such a deadly flu strain might be controllable, grave concerns remain: the drugs have limited efficacy even under conditions of ideal use and supplies are limited. Worse, the United States can manufacture only enough vaccine, even under emergency conditions, to protect some citizens, and most of the world lacks any capacity to manufacture vaccine. In a pandemic, the United States would face the foreign policy implications of denying vaccines to billions of people while saving the lives of some of its own. WHO conservatively estimates, even with widespread vaccine and drug use, this pandemic could potentially infect up to 30 percent of the world’s population of six billion people, with approximately seven million deaths.
The Next Steps
The international community does not have its eyes on the right ball. HIV/AIDS is a devastating pandemic that requires a massive global campaign to reverse its course of societal destruction. But HIV/AIDS does not exist in a vacuum. It is impossible merely to reverse the course of the HIV/AIDS pandemic without addressing its companion epidemics of malaria, hepatitis, tuberculosis, and pediatric illnesses associated with orphans exposed to HIV.
One way forward is to integrate the prevention, diagnosis, and care of these interconnected diseases. The diagnosis and testing for all of these diseases would be matters of life-saving routine. Basic research would go hand-in-hand with treatment programs, not shoved to the side as an inconvenient impediment. Prevention and treatment of any particular disease would not be segmented off from others because of jurisdictional boundaries of a certain UN agency, US federal bureaucracy, or international program. Buttressing these efforts must be an infectious disease surveillance system that can synthesize well-founded data from around the world to stem potential scourges (such as SARS and avian flu) before they escalate to overwhelming, not to mention expensive, epidemics. The only way truly to achieve this is through comprehensive integration and communication.
Compartmentalizing HIV intervention programs has, from the beginning, reduced its potential for success. The only effective and sustainable way to reverse the course of the HIV/AIDS pandemic and its companion epidemics is to de-exceptionalize it. Stand-alone HIV prevention and care clinics should not exist. HIV and tuberculosis ought not to be treated as stigmatized outlier syndromes. Syphilis, gonorrhea, hepatitis C, pediatric dysentery—all must come under one tent. And in building that tent the world needs to recall that nearly 75 percent of global wealth is now in the hands of just nine nations, according to 2003 World Bank data. Combined, the poor countries of the world, representing the majority of the population, possess less than one percent of global wealth. By necessity, building a health tent must mean attracting funds from the wealthiest nine states to the needs of the poor, on a massive and sustained level. Given the scale of the challenge, coupled with the constant emergence of new disease threats and potential for manmade scourges, the key for policymakers is to build alliances, work with and strengthen existing multilateral agencies, and avoid bilateral approaches that can undermine and alienate members of the international community.
Local support for these programs is also imperative. This support is two-pronged: community acceptance for the programs being administered is necessary for their success, as are human resource support systems to make the programs sustainable after the international community departs. Integrating services and de-exceptionalizing HIV will go a long way to minimize the stigmatization of this disease and increase community “buy in.” To begin to repair the human capital issues, the obvious yet daunting answer is to lessen the developed world’s demand for foreign health care workers while creating incentives for developing countries’ health workers to stay home. These changes will not occur overnight, but even a gradual shift away from the current trends can make a substantial difference in program effectiveness and begin to reinforce the local confidence level that has been eroded by years of failed promises.
Strengthening multilateral institutions, building local capacity, and improving communication and coordination between agencies will not be an easy task. Humanitarian and development agencies are not known for their ability to play well with others, and many world leaders continue to deny the global catastrophe that is waiting for them if they continue to neglect the need for focused and realistic infectious disease interventions. In contrast to their relatively low ranking on foreign policy priority lists, these issues represent an immediate threat to the security and stability of both the developed and the developing world and can no longer be overlooked.
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