The shocking assassination of Benazir Bhutto was not the only news of global significance to come out of Pakistan in the final days of 2007; the World Health Organization reported that the first ever case of human infection by the H5N1 avian flu virus had been confirmed in Peshawar.
Last week's World Health Day has its focus is on protecting health from climate change. However this post revisits the still current (but out of the news cycle) theme of World Health Day 2007 - international health security. It gives a broad overview of the current state of preparedness against the threat of pandemic disease. It then goes on to suggest that while progress has been made at the level of individual states, more can be done to enhance an overlooked aspect: going beyond coordination and moving towards the building of a transnational element into domestic preparedness programs.
Current State of Preparedness
It is unsurprising that the state of preparedness varies widely across the many nation-states of the world; it is also unsurprising that wealthier states are better prepared in all aspects, ranging from planning to pharmaceutical stockpiling, from public health infrastructure to nationally integrated continuity and rapid response systems. The World Bank-UNSIC Third Global Progress Report on Avian Flu Activities & State of Pandemic Preparedness (PDF) as well as the WHO's Dr David Nabarro (The Global State of Influenza Pandemic Preparedness, 10 Jan 2008) have noted these trends, acknowledge that progress has been made, collated best practices and lessons learnt thus far as well as identified priorities such as keeping a close eye on animal to human infection.
Borderless Threat, National Programs
Last year PM Lee spoke about the need for greater cooperation and collaboration, more openness and transparency, as well as translating actions into words. Key areas would include monitoring, vaccine research, stockpiles of anti-viral drugs and other pharmaceutical equipment, working more closely with the veterinary and agricultural sectors.
Numerous nationally-based but internationally accessible monitoring systems have been put in place. And collaboration on vaccine research made the news made the news more for problems (such as the Indonesian case) in collaboration than progress (Pandemic Influenza Vaccines Workshop Report, PDF, Jan 2007). ASEAN continues to make many fine declarations that have, so far, been little more than the usual aspirational banalities (de)coupled with little concrete action.
Preparing Domestically, Conflicting Internationally
The core worry of this post is not just the depressing lack of positive concrete international coordination but how domestic preparedness/rapid response programs can actually interfere with each other. One example is how the rush by developed Western countries to stockpile vaccines and anti-virals, such as tamiflu, has meant that, until about last year, Roche had difficulty keeping up supply and that poorer states were relegated to the back of the queue.
Another area that does not get much press coverage is the relatively unglamorous but essential supply of non-vaccine/anti-viral medical supplies - thermometers, N95 respirator masks, surgical gowns and so on. Due to the spread of Just In Time inventory management, many states do not hold large inventories of these items even if they do not have the manufacturing capabilities to produce them. Lobbying for US federal legislation (and funding) for maintaining domestic manufacturing capacity of such products, the Coalition for Breathing Safety noted: 'The [2003] experience with SARS showed that countries will embargo exports of respirator masks in the case of a global pandemic.' Some of us might remember the miserable scramble for masks and thermometers in the early days of the crisis.
During the discussion that followed Prof Barry Kellman's IISS presentation (related post), this topic came up. Prof Kellman recounted how he was horrified to hear senior US legislators declare that not a single iota of vaccine, anti-virals or essential medical protection equipment would be allowed out of the US. He described this type of thinking as short-sighted and stupid, ignoring how disease does not respect borders and the best way to protect public health was to stop infections at the locality of the initial outbreak.
In a similar vein, Prof Ann Marie Kimball observed: 'Countries with relatively poor economies, such as Indonesia, do not have the capacity to stockpile antiviral as do wealthier countries, such as Singapore. Experience has shown, however, that with transborder traffic flu quickly spreads to all economies if not controlled effectively at the primary site of transmission.' [1]
Transnational Pandemic Preparedness
Thus a transnational component for domestic preparedness programs could play an important part for domestic as well as international health security. Preparations could be made to designate portions of vaccines, drugs, medical supplies stockpiles as well as teams of skilled personnel for rapid deployment to help contain serious outbreaks in the region. The experience of Ops Flying Eagle in the aftermath of the 2004 tsunami could be instructive in some respects although any assistance would be more effective if there were stronger information-sharing, planning and coordination processes in place before hand.
I am troubled by the possibility of creating moral hazard but suspect that the fact that aid transfers between sovereign states is not unconditional may act as a sufficient deterrent. Preparing for and managing response to pandemic disease within one state is already a huge challenge [2], working to prepare and manage a pandemic crises between two or more states will be even more difficult. But the hope of this post is that such preparations will get underway soon - When the going gets tough, the tough get a bloomin' move on!
References
[1] Ann Marie Kimball, 'When the Flu Comes: Political and Economic Risks of Pandemic Disease in Asia' in Ashley J. Tellis and Michael Wills (ed), Strategic Asia 2006-07: Trade, Interdependence and Security (Washington D.C.: National Bureau of Asian Research, 2006), 385.
[2] Barry Kellman, Bioviolence: Preventing Biological Terror and Crime, (Cambridge: Cambridge University Press, 2007), 168-84. Key decision points include the hows and whens of compulsory vaccination for first responders, placement of victims, stockpiling and disbursement of stockpiles, compulsory medical interventions such as quarantine zones.