Global Health and Foreign Policy Blog

Richard Holbrooke, former U.S. Ambassador to the UN and CEO of the Global Business Coalition on HIV/AIDS, suggests in the Washington Post that we may be seeing a change in Chinese foreign policy towards greater cooperation with the U.S. on issues of mutual concern. He cites as evidence increased Chinese diplomatic pressure on the governments of North Korea, Sudan and Burma (Myanmar) that has shown some small (but still insufficient) impact in negotiations with these states.

The ends toward which China directs its increasing foreign policy clout will have a major impact on global affairs, but it’s not just traditional foreign policy that interests China. The Chinese Ministry of Science and Technology announced yesterday “efforts to establish a biological security system in 20 years to fight against bio-terrorism and prevent serious epidemic diseases.” This raises big questions about the scope of this system, its linkage with other global surveillance efforts, the sharing of data on disease outbreaks, and the ends toward which the proposed Chinese biological security system is directed. While these questions play out, I think we can expect China to play an increasingly important and assertive role in global health security efforts.

The big health news out of India this month is that a new Gates-funded study puts the total number of people infected with HIV/AIDS in India at between 2 – 3 million people. That is half previous estimates of the Indian epidemic, which was considered by some to be the world’s worst in terms of total number of people infected. (South Africa, with an estimated 5.5 million cases, will retain this dubious title.) The study suggests that the virus is mostly prevalent in high risk groups, and has not spread widely in the general population. The combination of concurrent sexual relationships and transactional sex that have so greatly exacerbated the epidemic in Sub-Saharan Africa does not seem to be operating in India.

If this new study is accurate, previous estimates of HIV in India were 50% higher than actual rates. There can be reasonable reasons for such a revision of estimates. The methods used in studies are different, and results can be greatly affected by which populations are sampled and how representative they are of the general population. But Daniel Halperin at the Harvard School of Public Health suggests in the New York Times article that there is a more nefarious reason behind the revision of estimates: “that that AIDS-fighting agencies had such a stake in portraying the epidemic as an approaching Armageddon that they were hesitant to make revisions.” If the downward revision of HIV prevalence in India, and similar revisions in Kenya, Mali and Zambia, are due to improved sampling or actual reductions in HIV prevalence, great. If public health agencies are hyping the scope of the epidemic by delaying the reporting of estimates that are lower than previously thought, they stand to lose one of public health’s only advantages in global politics: scientific credibility.

The new set of International Health Regulations (IHR), an update of the only international agreement on infectious disease control that is binding on WHO member states, will take effect on June 15, 2007. The arrival of the new set of rules has been heralded by some as a revolution in the fight against communicable disease and a high point for international health cooperation. While there is every reason to believe the new IHR represent an important step forward, it is also clear that they will not (and cannot) fix long-standing weaknesses in the international public health system. Until deeper problems are addressed, the IHR will remain a well-intentioned, but incomplete, instrument of global public health.

There are two key improvements in the new version of the IHR. First, it greatly expands the scope of internationally notifiable diseases. While only three diseases were reportable to WHO in the previous IHR (cholera, yellow fever, and plague), the revised version requires reporting on any event that constitutes a “Public Health Emergency of International Concern.” This theoretically requires countries to notify WHO of all existing and any new infectious diseases with a potential to spread internationally. Second, it allows for the inclusion of non-state information in notifications of disease outbreaks. Previously, WHO was constrained to reporting only disease outbreaks that had been officially recognized by the country experiencing the outbreak. The new IHR allow WHO to use third-party information (such as reports from other countries or from non-governmental sources) to publicly identify outbreaks even without official verification from the affected country.

While these changes are needed and are very welcome, there are two major problems contributing to global disease insecurity that the new IHR do not remedy.

First, disease surveillance capacity in many countries is poor to non-existent. The security provided by a global public health system is dependent on the effectiveness of its component domestic systems to provide timely and effective epidemiologic information, and many countries struggle to identify and track diseases. The new IHR acknowledge this weakness and urge rich countries to “provide support to developing countries…if they so request, in the building, strengthening and maintenance of the public health capacities required under the IHR”, but no solid, enforceable mechanisms for coordinating such a development program is outlined.

Second, the global health system is still comprised of sovereign states that place their own interests above all else. Mistrust and concealment is still a problem among countries and between countries and the WHO. For example, despite the looming threat of a devastating worldwide avian influenza pandemic, human and animal cases of the disease regularly go unreported, and some countries have been reluctant to share samples of the virus. Often, the reason for the lack of transparency is a fear of the negative economic repercussions from reporting a disease outbreak, which could lead to travel restrictions or a ban on exports. No effective measures currently exist to provide a counterweight to these often legitimate national concerns, and therefore secrecy will continue to hamper global disease control.

The IHR may represent an important health diplomacy tool, but the solution to the problem of international infectious diseases lies in addressing the global goods problem of funding the development of a true global capacity to identify and track diseases, as well as creating a responsible framework for incentives for countries to communicate quickly and openly about disease outbreaks. These solutions will not come from one international treaty, but from an extended multilateral effort with leadership coming from rich countries who realize that the best way to protect themselves from infectious diseases is to create a truly global disease control system.

The story of Andrew Speaker, the handsome newlywed who put the public’s health at risk by traveling to Europe to attend his wedding, has been headline news. Speaker has Extensively Drug-Resistant Tuberculosis (XDR TB), a form of TB resistant to nearly all drugs used to treat TB.

In traveling, Speaker put other people at risk. That an educated person could do this—a person whose father-in-law is a TB expert—only adds to the vulnerability people feel now.

The situation is not unique. Remember the SARS epidemic of 2002-2003? That disease was spread outside of China by a doctor who had been treating SARS patients in Guangdong province. He probably infected others by coughing. It is known that he infected at least 16 other people, all of whom spent at least some time on the ninth floor on the Metropole Hotel in Hong Kong.

People are right to be worried about spread. As one passenger on board the same flight as Mr. Speaker put it, “How many other people can do this or will do this? It’s hard to think about what this means for the future of air travel.” See full article here.

Policy, however, has to think about much more than border controls, travel restrictions, and quarantine. How did Mr. Speaker get infected? How did the person who infected Mr. Speaker get infected? How, especially, did the first person to acquire XDR TB get the disease? This person is especially important. Epidemiologists call this person the “index case.”

Newly emerging diseases can be prevented—or at least their chance of emerging can be reduced. The exotic wildlife markets in China played a role in the emergence of SARS. Similarly, a mutation of the avian flu virus H5N1 capable of human-to-human transmission is more likely to emerge where large numbers of people come into contact with large numbers of birds. In the case of XDR TB, emergence is likely to have been made more likely because of inappropriate drug use. The index case for XDR TB has not been identified, but this disease is almost certain to have emerged outside the United States.

There is a tendency for policy to respond to a situation like this by focusing on the need to throw up border controls. Such controls are needed, but so are other measures. In particular, we need better surveillance worldwide for emerging diseases like XDR TB. We also need policies that make emergence much less likely. Global standards for TB exist. Lacking are the carrots and sticks that create the incentives for countries worldwide to abide by these standards.

To protect the U.S. population, United States policy needs to look outwards and not only inwards (border controls). The U.S. cannot address risks like this unilaterally. A global approach is needed, but that will not be forthcoming without U.S. leadership—a reason why the intriguing case of Mr. Speaker should be a priority for U.S. foreign policy.