Global Challenges

“Our limited capacity for producing potentially lifesaving vaccines presents a pressing moral challenge. I believe wholeheartedly that all lives have equal value […], and I believe that every stakeholder has a responsibility to ensure that the pandemic does not take a 1918-like toll on the world. Rich countries have a responsibility to stand in line and receive their vaccine allotments alongside poor countries, even if they have paid for their vaccine before others could do so.”

– Tadataka Yamada, M.D., President, Global Health Program, Bill and Melinda Gates Foundation in the New England Journal of Medicine

There are three major challenges to mitigating a flu pandemic on a global scale:

The question of how to improve worldwide surveillance to catch a new outbreak at its source or at least to monitor how the virus is spreading and, possibly, changing.
The lack of access to medical interventions such as vaccines, antiviral drugs and antibiotics in developing nations, which are often already suffering from poor health conditions.
The concern about the global economic impact of an infectious disease outbreak that causes major disruptions in social life, productivity, and trade.

In this section, we will take a closer look at all three.

On this page...
  Weaknesses in surveillance systems »
  One world, two realities »
  Story idea: Who is helping, and why? »
  Flu and the global economy »

Weaknesses in surveillance systems

Tracking the spread and severity of a disease as it moves from region to region requires close cooperation among governments and health authorities worldwide.

At times, though, international coordination and cooperation runs into resistance from countries or regions where people are skeptical of the motives of Western nations. In 2006, for example, authorities in Indonesia—the country with the most confirmed human cases of H5N1 infection—stopped sending samples from infected persons to the WHO as a protest against the high cost of vaccines. There was also the allegation that the United States intended to produce a biological weapon with the H5N1 virus. Although Indonesia resumed sending some samples to the CDC in 2008, tensions over who owns and gets to benefit from virus samples remain.1

In another example, competing interests came out into the open in 2006, when Italian virologist Ilaria Capua decided to file information about the genetic sequences of H5N1 avian flu viral samples she was studying into a public database where researchers from around the world could examine them instead of a WHO database with more restricted access.2

In January 2008, the U.S. Government Accountability Office (GAO) issued a report, “Influenza Pandemic: Efforts Under Way to Address Constraints on Using Antivirals and Vaccines to Forestall a Pandemic,” which looks, in part, at worldwide preparedness.3

The GAO found that in many countries with H5N1 avian flu infections—the strain that threatened a pandemic at the time—weaknesses in surveillance systems meant that antiviral drugs and vaccines might be delayed in reaching the source of an outbreak, thus risking its expansion into a pandemic. "If early signals are not identified,” the report states, “the opportunity for preemptive action will be missed." Antivirals should be administered within 48 hours of symptoms to be effective.

The GAO also pointed out weaknesses in various countries in reporting cases of influenza in animals, as well as collecting samples of the virus.

The WHO has set a target date of June 2012 for countries to develop certain basic public health capacities, which would address the concerns identified in the GAO report. These requirements were adopted as part of the International Health Regulations treaty and cover a variety of public health emergencies, not just pandemic flu. (For more information, visit the IHR Web site.)

One world, two realities

Developed countries command significant resources to prepare for and respond to an influenza pandemic. Most developing nations are not so fortunate: In many regions, people can barely afford basic health care, such as readily available vaccinations or maternal care. People who are already suffering from malnutrition, HIV/AIDS, tuberculosis or other ailments will be more susceptible to complications and death from the flu. Neither individuals nor their governments can afford pandemic flu vaccines or antiviral drugs.

“I did a survey among my 193 member states asking, ‘Do you have access to vaccines?’”, WHO Director General Margaret Chan said in a Newsweek interview in Oct. 2009. “Eighty-five said, ‘No way.’”

A 2006 study published in The Lancet projected that, if a 1918-19-like pandemic were to happen, 96 percent of the deaths would occur in the developing world.4

To address some of the obvious inequalities, officials at WHO and the UN have rallied up support from both pharmaceutical companies and wealthier nations.5

Some countries, such as the United States, Brazil and France, agreed in October 2009 to make 10 percent of their national vaccine stockpile available to developing countries. And manufacturers donated about 150 million doses of vaccine.

Story idea: Who is helping, and why?

An August 2009 “Report to the President on U.S. Preparations for 2009-H1N1 Influenza” by the President’s Council of Advisors on Science and Technology takes a clear stand on this issue. It states: “While recognizing that issues with basic health infrastructure in developing countries cannot be remedied in the short run, the availability of materials—including 2009-H1N1 vaccine, antiviral medications, antibiotics, personal protective equipment, and other essential materials—may help mitigate the impact of the epidemic.”

The report recommends that the United States government provide not just vaccines, antiviral drugs, antibiotics and other medical material to developing nations; but that the government use its influence on other developed nations to do the same; and that it investigate efforts to make more vaccine doses available by preventing inappropriate use or even promoting the use of adjuvants.

How has the Obama administration responded to these recommendations? Which countries are leading the efforts to support poor nations, and which countries are not? Note that there are more than humanitarian interests behind these recommendations: Fast-spreading infectious diseases can only successfully be defeated if they subside everywhere, and disruptions in the global economy are a major threat to all nations, rich and poor.

Flu and the global economy

The numbers vary from study to study but the overall message is clear:If a severe flu pandemic swipes across the globe, economies worldwide will be slowed down, and some of them may collapse.

Within one year of the outbreak, says one World Bank study, costs to respond to the pandemic would rise to $800 billion, or two percent of annual global output.6

The effects would be most devastating for developing countries, where economies might shrink in half as capital fled across borders to safer locations, estimates Professor Warwick McKibbin of the Lowy Institute for International Policy in Australia.

While the World Bank and the International Monetary Fund are prepared to provide instant loans to countries in need should a severe pandemic result in major economic losses, international collaboration on preparing for the economic impact of a flu pandemic has only started in recent years. Efforts are focused on including poor countries in vaccine distribution (see above) and, in the case of the U.S., on providing additional foreign assistance in form of medical and technical advice and supplies.8


  1. Center for Infectious Disease Research & Policy, CDC expecting H5N1 samples from Indonesia, CIDRAP News, Feb. 22, 2008.

  2. David Brown, “Bird Flu Fears Ignite Debate on Scientists' Sharing of Data,” Washington Post, May 25, 2006.

  3. United States Government Accountability Office, Influenza Pandemic: Efforts Under Way to Address Constraints on Using Antivirals and Vaccines to Forestall a Pandemic, December 2007.

  4. C.J. Murray, A.D. Lopez, B. Chin, et. al., “Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis,” The Lancet 368 (Dec. 23, 2006): 2211-2218.

  5. “Share H1N1 vaccines with poor countries, U.N. urges,” Reuters, Oct. 4, 2009.

  6. Tom Wright, “World Bank Creates $500 Million Loan Plan to Combat Bird Flu,” International Herald Tribune, Nov. 7, 2005.

  7. Warwick McKibbin, Global macroeconomic consequences of pandemic influenza, The Lowy Institute for International Study, The Australian National University, February 2006.

  8. President’s Council of Advisors on Science and Technology, Report to the President on U.S. Preparations for 2009-H1N1 Influenza, Aug. 7, 2009.

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