Much of the domestic discourse on preparedness for the second wave of H1N1 has focused on the speed with which a vaccine has been produced, which ignores a striking fact: ninety percent of H1N1 vaccine stocks will be distributed to individuals in the U.S., and eleven other wealthy countries, while the rest of the world must make due with the remains.
As the 95 poorest countries wait for vaccine donations from the U.S. and elsewhere to arrive, which will only allow them to vaccinate just two percent of their populations, the Netherlands has begun to sell off surplus vaccine stock. This inequality in access has sparked criticism from public health and human rights advocates, who argue that there is an epidemiologic and moral imperative to ensure vaccine availability in poor countries. Though these criticisms may be valid, they fail to address a more politically persuasive point that lack of access to vaccinations in low and middle-income countries imperils domestic public health and national security. Ad hoc vaccine sharing is not only an incomplete strategy for managing global health threats, but it also leaves the U.S. population vulnerable.
There are several reasons why it is in the interests of the United States to enhance global vaccine access and pandemic response capacity in low and middle-income countries. First, the current vaccine allocation arrangement ensures that countries with the least capability for managing a pandemic also have the least access to life-saving vaccines and medicines, thereby perpetuating the cycle of illness and poverty in poor countries, and creating fertile ground for new or re-emerging viruses to replicate, mutate and eventually spread back to the United States.
Moreover, during a more virulent outbreak, the U.S. could be exposed to broader economic risks due to disruptions to the "just-in-time" global economy. In 2003, the poorly managed SARS outbreak halted travel and trade in Southeast Asia and cost an estimated $50 billion in that region alone.
Finally, the majority of vaccines (including H1N1), as well as essential medical supplies such as facemasks and ventilators, are manufactured abroad. A severe pandemic with high rates of illness and death could lead to rampant absenteeism from work, or worse, hoarding in countries that produce and manufacture these goods. The risk of hoarding is increased if there is a persistent perception that wealthy countries act according to narrow self-interest during global health emergencies. Unfortunately, this has already happened. Indonesia has refused to share virus samples and report cases of the deadly H5N1 flu virus to the World Health Organization (WHO) for fear that wealthy countries would use this information to produce costly drugs and sell them back to poor countries at a profit. While the reasoning is severely flawed and endangers the health of people all around the world, it reveals the potential consequences of persistent inequality in access to essential medicines.
The H1N1 experience has taught us that a more robust U.S. response must address the inadequate global supply of vaccine during pandemic emergencies, often called "surge capacity," and enhance low and middle-income countries' domestic response capabilities.
Work on expanding the supply and domestic production capacity is underway, and the U.S government should continue to support newer production approaches, such as cell-based or DNA-based vaccines, which can help to mitigate current surge capacity shortfalls. To complement these efforts, the U.S. FDA should expedite the review of safety and efficacy data of adjuvant-boosted vaccines. Adjuvants serve as a multiplier, exponentially increasing the number of people who can be immunized by a given amount of vaccine, and they have been extensively tested and used in Europe and Canada safely for years. Contrary to the spurious rhetoric from the anti-vaccine movement, adjuvant use in the U.S. would enable the demand for domestic vaccine to be met rapidly and safely. It would also enhance our ability to supply vaccine to poorer countries.
In addition to stimulating vaccine production, the U.S. should devote additional financial and technical resources to building disease surveillance and response capacity in developing countries. Most importantly, the world needs a formal governance mechanism for pandemic emergencies that procures, stockpiles and distributes vaccines and supplies for developing countries to replace the current system of ad hoc donations. The G7 plus Mexico recently met to discuss equitable vaccine distribution; the United States should ensure that such a mechanism is part of ongoing discussions.
H1N1 will not be the last or worst pandemic humanity will face. It should therefore serve as a "teachable moment" for the U.S. and other donor nations. Poor countries' inability to manage pandemic emergencies poses a threat to health everywhere. International solidarity on pandemic management guided by enlightened self-interest is not only the right thing to do and good foreign policy, it is essential to ensuring the health and security of the U.S. citizenry.
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