By Dele Ogunseitan
On Thursday 11 June 2009, Dr. Margaret Chan, Director General of the World Health Organization (WHO) invoked the highest level of global alert (level six) based on human morbidity and mortality associated with influenza A virus (H1N1 or swine flu);
essentially declaring a pandemic – the first since 1968, 40 years ago. At the remarkable press conference in Geneva, the announcement provoked numerous questions and lots of uncertainties in the responses: How severe is a “moderate” pandemic? Are countries allowed to unilaterally close their borders? Suspend travel? Be more selective about trading partners? Restrict immigration?Hoard vaccines? In addition to the current prevalence of H1N1 and its pandemic status, there is another virus (H5N1) that represents a looming threat, currently at level-3 alert.Together, these two viruses raise the prospects of worldwide panic. The experts are moderately worried, but insist that panic is not warranted – yet. Incidentally, no country in sub-Saharan Africa has reported a single case of swine flu, and the continent remains remarkably free of the disease weeks after its emergence. What does this really mean for global health? That Africans do not travel much, are resistant to swine flu, or do not have the infrastructure to discover, test and report cases to a global database? The politics associated with the naming of H1N1 as a pandemic despite these knowledge gaps demonstrate the difficulties of defining “global health” and arrogating resources for this
“new” enterprise, issues that ministers of health in most countries are now forced to confront head-on.
After nearly a decade of efforts to define “global health” and its contested agenda[1]; of developing internally consistent metrics of the global burden of disease; and of witnessing the emergence of trans-boundary financial magnates who assert their considerable influence on specific globalized diseases, we have finally arrived at a juncture at which economic and public health crises openly collide. In his inaugural $3.55 trillion budget proposal, U.S President Obama outlined a plan to increase foreign spending by as much as 10% in the 2009-2010 fiscal cycle, but there are fears that investments in political maneuvering at the global level will diminish the focus on global health. For example, the first week in May 2009 when the swine flu emerged in Mexico city, the U.S. government had no permanent director for the Center for Disease Control and Prevention; no head of the
Department of Human and Health Services; and no permanent Director of the National Institutes of Health. Certainly, “health care reform” has been high on the agenda of every presidential candidate since Bill Clinton, only to sink low in the agenda of priorities to be implemented because the sense of urgency associated with public health has been lacking compared to the “war on terror” and now in 2009, global economic calamity. The flu pandemic was certainly a wake-up-call to the U.S. government to quickly fill some of the administrative positions dedicated to public health care. And to the international agencies struggling with overlapping epidemics of neuropsychiatric conditions, heart disease, cancers, AIDS, tuberculosis, malaria, and injury, the true nature of emergency health care was revealed, along with uncertain effectiveness of public health preparedness infrastructures that have not been fully tested in four decades since the declaration of the Hong Kong flu pandemic that killed 33,800 people over the six month period between September 1968 and March 1969[2]. Meanwhile, many diseases in the list above continue to kill millions of people annually without the fanfare associated with official pandemic declaration and nobody seems to care where on
WHO’s scale of 1 – 6 these persistent pandemics reside.
Although the Obama administration is facing one of the largest budget deficits in U.S. history, there is a sense that commitment to global health is no longer just about noblesse oblige – affluent countries caring for the plight of the unfortunate equatorial peoples – but that we Americans are as vulnerable to global threats to public health as the poorest societies, and we contribute our fair share to the amplification of modern risk factors such as climate change. It is now widely recognized that global health emphasizes problems that transcend geopolitical and economic boundaries[3]. But there is no consensus regarding the best strategies for making an impact in global health toward reducing the burden of disease at the global level. On this question the confluence of
money and politicss become critical. A number of foundations and agencies adopt the “disease eradication” approach, where there is an exclusive focus on a single pathogen or risk factor and the funds flow toward development of a cure for the affected disease (see Uli Beisel’s accompanying post). An alternative or complementary approach is emerging in global health with emphasis on composite strategies that can prevent a wide range of diseases associated with, for example, behavioral or environmental modifications. The new strategies include a variety of intervention programs heavily influenced by socio-economic incentives and sensitivity to cultural values and differential weights attributed to the impact of specific diseases in different regions. The Obama administration seems to be sympathetic to this latter “global” approach to “global health.” For example, reversing the embargo placed on family planning and abortion rights by the previous administration would be a way to improve maternal education and choices that can help reduce the burden of diseases associated with women and children. This strategy may be cost-effective for
long-term planning for global health, but we will, in all likelihood, continue to face the periodic emergence of threats such as the swine flu where our attention will be nearly exclusively focused on a single disease with the concomitant dedication of dwindling sources of funds available to tackle complex global issues.
Fortunately, a new generation of scholars is attracted to the transdisciplinary nature of global health, and with support of organizations such as the NIH’s Fogarty International Center (http://www.fic.nih.gov/), students across all educational spectra are
eager to become engaged early. This is an opportune time to translate the potential energy accumulated through the “official pandemic flu” quiescence over the past 40 years into a period of sustainable engagement with global health, not just for diseases thatattract the press corps to the WHO conference room in Geneva.
Dele is Professor of Public Health and Professor of Social Ecology, College of Health Sciences in the School of Social Ecology at the University of California, Irvine. Contact him at oladele.ogunseitan@uci.edu.
[1] Koplan et al., June 2009. “Towards a common definition of global health” in The Lancet, 373:1993-1995 – proposed the universal adoption of the following definition: “Global health is an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.”
[2] U.S. Department of Health and Human Services. “Pandemics and Pandemic Threats Since 1900.” (http://www.pandemicflu.gov/general/historicaloverview.html).
[3] Brown et al., 2006. The World Health Organization and the transition from “International” to”Global” Public Health.AmericanJournal of Public Health, 96 (1) 62 – 72.