The global response to swine flu: 'the brighter side of globalisation' or just reinforcing inequalities?

The response to the swine flu crisis has laid bare the gross inequalities between rich and poor countries and the difficulties of tackling a global pandemic in a divided world, says  Marion Birch.

THE present response to swine flu has all the characteristics of a well-coordinated global programme with the World Health Organisation (WHO) taking a lead role, lessons learnt from previous pandemics, priority research to develop a vaccine and the virus closely monitored for signs of mutation. It builds on the experience of dealing with severe acute respiratory syndrome (SARS). Margaret Chan, WHO Director-General, at the 23rd Forum on Global Health Issues in Germany in March 2009, referred to the global collaboration that contained the spread of SARS 'within four months' as 'the brighter side of globalisation. This is an example of collaboration and solidarity before a shared threat'.

Accurate numbers are understandably difficult to produce in what WHO has described as the 'fastest-moving pandemic ever'.1 On 16 July WHO advised that it was pointless to count individual cases and revised its requirements; national health authorities are now only expected to report clusters of severe cases or deaths, or unusual clinical patterns. Laboratory confirmed cases that had been reported to WHO by the end of July indicate that the most cases occurred in the WHO Regional Areas of the Americas, the Western Pacific and Europe. As the number of cases is highly speculative, trying to estimate mortality rates using these numbers becomes almost meaningless. By 31 July a total of 1,154 deaths had been reported to WHO globally.2

The degree of surveillance and reporting will depend on existing systems and infrastructure, and the competing demands on the time of those who staff them. While only 229 confirmed cases and no deaths were reported in the WHO African region up to 31 July, this says nothing about the actual situation or potential threat to African countries. An indication of what they may be confronted with was the outbreak of influenza caused by the H3N2 virus strain in July 2002. More than 70% of the inhabitants of Sahafata village in south-east Madagascar suffered from acute respiratory symptoms and 1.8% (27 people) of them died. An assessment of the response showed that those with symptoms were hard to reach, there were insufficient antibiotics to treat secondary infections, there was no intensive care unit for those who needed one, and awareness of influenza was low among the population.3

For those working in countries worst affected by the diarrhoeal diseases that still kill 2.5 million children a year, prioritising a disease that has killed 1,154 people - on available figures mostly in richer countries - in approximately two months must raise some searching questions. Health workers globally recognise the value of containment and prevention; however, the present global response is far from even-handed.

In her 23rd Forum on Global Health Issues speech, Margaret Chan also said that '.... equitable health outcomes should be the principal measure of how we, as a civilised society, are making progress'.4 The problem for WHO - and for all of us - is that, as with all global responses, the response to swine flu is taking place in a context of gross inequalities; and the nature of a global response, to a rapidly spreading communicable disease is a very difficult environment to confront these inequalities.

The media: a mirror of inequality

The concerns - real or media- driven - of the richer world hold up a mirror to both the inequalities that underpin the response to swine flu, and the difficulties of addressing them in a global pandemic.

The press in the UK have gone full circle from reassurance to alarm. Case studies have featured school- children speculating about becoming the school hero by getting their school closed down5 and parents reassuringly reporting that their son is 'absolutely fine but bored stiff'.6 One article describes how swine flu has 'swept across the world killing at least 300 people' - this in a country where an estimated 28,000 people would have died of circulatory-related disease in the same period.7 Then there has been a heated debate in the media about the consistency of the advice given by the Department of Health and the Royal College of Midwives, on whether or not pregnant women should go to public places.

For an individual expectant mother clear guidelines are of course very important, and in the rich world an increasingly risk-averse and individualistic environment can put considerable pressure on individuals to make the 'right' decision. However, consider this dilemma for an expectant mother making her living through marketing in one of the poorer countries of the world. She is very unlikely to stay home and forfeit a day's income when she feels well, because of a risk (of unknown magnitude) of contracting a disease (that probably won't kill her). She simply cannot afford to, and the loss of income with which she supports her family is almost certainly a greater risk to her.

Pandemics, priorities and profits 

What pandemics like swine flu should do is draw more attention to global inequalities. But because of the risk to their citizens - and the prevailing status quo - the rich world tends to be preoccupied with the immediate response. There is recognition that, for example, vaccines should be provided free8, but little evidence that the pandemic is recognised as yet another urgent reason why underlying inequalities need to be addressed.  Treatment, individual protection and a vaccine have dominated as priorities; and for those that make Tamiflu, face masks, testing kits, and potentially the vaccine, there are huge profits to be made.

Tamiflu (oseltamivir) has been stockpiled by governments, individuals and private companies, and sold over the Internet in what has become effectively a market free-for-all. Its side-effects have been debated and its shelf life has grown - this increased to three years in 2002 and is now officially five years but is cited as anything up to 10 years. Yet this is a drug that can only reduce the effects of symptoms, and its effectiveness could easily be reduced with further mutations of the virus. Pockets of resistance to oseltamivir have been recorded since early 2008. 

Dr David Navarro, senior UN System Coordinator for Avian and Human Influenza, has said WHO representatives and the UN Secretary-General have agreed with pharmaceutical companies that developing countries will have access to necessary vaccines. 'There will be a proportion of total vaccines manufactured set aside for and then to be made available to least developed countries, it will be made available at an extremely low price.'9

It remains to be seen how vaccine pledges are realised in practice. Meanwhile special fast-track mechanisms for approval and licensing of the vaccine have been put in place.10 GlaxoSmithKline (GSK) - selected by WHO to manufacture the vaccines - is set to make huge profits by the end of 2009.11 One hundred and ninety-five million doses had been ordered by 23 July - a lot less than eventually expected, according to GSK's chief executive. The UK alone has ordered 132 million doses - two doses for every citizen.

Meanwhile India may be producing its own vaccine by September. The Indian Council for Medical Research and the National Institute of Virology isolated the virus from a local case and Indian companies have received the seed stock as a contribution to vaccine development from the Centers for Disease Control in Atlanta.12

However, the inequitable distribution and a lack of commitment to address this led Margaret Chan to say on 2 August that 'Manufacturing capacity for influenza vaccines is finite and woefully inadequate for a world of 6.8 billion people, nearly all of whom are susceptible to infection by this entirely new and highly contagious virus. The lion's share of these limited supplies will go to the wealthy countries. Again we see the advantage of affluence. Again we see access denied by an inability to pay.'13

Just wash your hands...

In the ongoing, somewhat schizophrenic atmosphere of reassurance and alarm in richer countries, the value of basic preventive measures is stressed. This should also draw attention to inequalities. Professor John Oxford, chairman of the Hygiene Council (sponsored by LYSOLr) and Professor of Virology at St. Bartholomew's & The Royal London Hospital, assured 'families around the world' that 'the pandemic declaration is simply a reminder to families to follow proper hygiene routines to help protect themselves'.14 One of the recommendations is to '...wash your hands frequently with soap and water...dry your hands thoroughly with a clean dry towel. If soap and water are unavailable use a hand sanitiser.' The impracticality of this for the one in eight of the world's families who do not have access to safe water, sanitation and hygiene is glaring.

As much as possible must be done to protect those in less well-resourced countries from the swine flu pandemic. Robert Orr of the Executive Office of the UN Secretary-General has said that 'The flu season, as was expected, in the Southern Hemisphere is unfolding and, as we see right now, some developments in countries like Argentina where there's more than a 10-fold increase in people in hospitals, a number of other countries in the Southern Hemisphere are showing some signs of dramatically increased activity.'15

This pandemic should be part of the wake-up call for recognising and addressing underlying inequalities. This will also be good for health in the richer world, where the increasingly individualistic and market- and media-driven approach to health means health emergencies are managed with overall inefficiency. The WHO Director-General Chan has said that many developing countries 'actually go into this pandemic what I call empty-handed. They don't have antivirals. They don't have vaccines. They don't have antibiotics'.16 This is just the tip of the iceberg of the underlying inequalities driven by global power structures and the economic system that underpins them.            

Marion Birch is Director of the global health charity Medact <www.medact.org>. 

Endnotes

1    'H1N1 pandemic spreading too fast to count: WHO'  Reuters 16 July 2009 http://www.reuters.com/article/worldNews/idUSTRE56F57U20090716

2    WHO Pandemic (H1N1) 2009 - update 60  31 July 2009 http://www.who.int/csr/don/2009_08_04/en/index.html

3    Enserink M (2009) 'Worries About Africa as Pandemic Marches On'  Science 7 August 2009 Vol 325

4    Margaret Chan DG WHO March 18 2009 Berlin 'The impact of global crises on health: money, weather and microbes' http://www.who.int/dg/speeches/2009/financial_crisis_20090318/en/index.html 

5    Case study: 'I'd prefer to get it now' The Independent 1 July 2009

6    Case study: 'He is absolutely fine but bored stiff'. The Independent 3 July 2009

7    Statistical Bulletin: Births & Deaths in England & Wales 2008  Office for National Statistics

8    GlaxoSmithKline PLC Government Orders For H1N1 Vaccine  4 August 2009 WSJ.com  http://online.wsj.com/artilce/BT-CO-20090804-713072.html

9    ibid

10   WHO Safety of pandemic vaccines 6 August 2009 http://who.int/csr/disease/swineflu/notes/h1n1_safety_vaccines_20090805/en/index.html

11   'Glaxo unmasked:drug firm to make œ1bn from swine flu' Alistair Dawber & Jeremy Laurance The Independent 23 July 2009

12   'India may have its own H1N1 vaccine by September'  5 August 2009 The Times of India http://timesofindia.indiatimes.com/articlesshow/msid-4858351,prtpage-1.cms

13   'Rich states' spending on H1N1 spurs ethics row'  2 August 2009 Paris (AFP) http://alarabiya.net/save_print.php?print=1&cont_id=

      80546&lang=en

14   'As WHO Raises Influenza A (H1N1) Pandemic Alert to Level Six, Hygiene Council Recommends Simple Steps to Help Protect Families from Illness'  15 June 2009 RedOrbit News http://redorbit.com/modules/news/tools.php?tool=print&id=1705084

15   '"North-South Divide"  for A H1N1' Nick Baker for UN Radio 17 July 2009 http://www.unmultimedia.org/radio/english/detail/78386.html

16   'UN chief says $1 billion is needed for the fight against swine flu' 6 July 2009 The Canadian Press http://ca.news.yahoo.com/s/capress/090706/health/health_un_swine_flu?printer=1

*Third World Resurgence No. 227, July 2009, pp 22-24