Let’s Attend to the Pandemic we Have, Rather than a Potential One
By Jeremiah Norris - Senior Fellow, Hudson Institute
WHO is proposing a Pandemic Influenza Preparedness (PIP) plan in the potential event of a global need. PIP covers the implementation of:
- disease-based surveillance capacities in 52 countries;
- laboratory strengthening in 75 countries;
- the establishment of WHO Collaborating Centres in 3 Regions;
- the expansion of influenza vaccine production in 34 countries;
- the expansion of potent adjuvant technology for 24 manufacturers;
- antiviral medicines for 9 million people in poor countries;
- and vaccines for 138 million people.
Aside from the numerous questions regarding the funding, governance, and operations of such an initiative, one cannot help but wonder why the WHO wants to allocate billions of dollars for a pandemic which has not happened yet, while ignoring the existing and seeming insurmountable problem of non-communicable diseases in developing countries.
In order to fund the Inter-pandemic and Pandemic event itself, WHO is recommending the formation of a PIP Endowment to receive annual, predictable funding from two principal sources: industry and government. The $1.850 billion would cover the early weeks/months of a pandemic. Subsequently, $86.2 million each year is needed to cover the next five years to undertake continuing preparedness activities, or $432.5 million.
The ten year cost for a PIP Endowment would then be $2.283 billion to fund a Global Influenza Surveillance Network with four income streams:
- a subscription fee from manufacturers’ annual sales of influenza products;
- in-kind contributions;
- and, foundations and other donors.
WHO comments on these requisite institutional characteristics for governance:
- the World Health Assembly and other WHO expert committees;
- an expertise in pandemic preparedness and response;
- an ability to ensure coordination of funding streams and technical support to countries;
- and, a mechanism for regular auditing, monitoring, evaluation, and reporting.
This is a job description written for a UN agency or one of its specialized agencies. It is reasonable to ask, then, what is its record over the past decade or so with the special funds created under UN auspices and conducted with WHO’s institutional support?
The largest in terms of dollar volume and of those addressing antiviral medicines and immunizations are the Global Fund to Fight HIV/AIDS, TB and Malaria, and GAVI. In February, the AP reported on four audits conducted by the GF’s Inspector General:
- in Zambia $3.5 million went undocumented;
- in Mali, 36% of the funds were misspent;
- in Mauritania, a full 57% of the money spent on AIDS programs was misspent,
- and, in Djibouti, 30% of the grants were misspent.
Subsequently, public notices were issued by Germany and Sweden to withhold/suspend their funding for 2011-2013. Ireland followed suit shortly afterwards.
GAVI is the largest organization involved in global immunization programs. The Bill & Melinda Gates Foundation has provide it with $1.5 billion over the past ten years, and the value of industry’s product donations are almost equal to that amount, not to mention foundation support and inflows from bilateral agencies, e.g., USAID. In a 2008 article, The Lancet, stated that “many of the world’s poorest countries have for decades routinely exaggerated the number of children being immunized”, e.g., specifically the 39 of the 51 countries which have received GAVI funding overestimated rates of immunization.
Overall, The Lancet found that “GAVI may have paid out twice as much for performance awards as it should have”.
In additional to these two UN-specialized agencies, there are other funding programs which operate as Health Alliances and Global Partnerships, some with Secretariats in WHO, wherein they are provided with immunities and privileges under the International Organizations Act (e.g., freedom from legal suit in any jurisdiction). For instance: UNITAID, which is funded via air line ticket taxes; UNAIDS, funded by bilateral and multilateral donors; the Medicines for Malaria Venture; the Fund for R&D in Neglected Diseases; the Global Drug Facility; the Tropical Disease Research Programme—funded entirely by non-dues of WHO Member States; the Extra Budgetary Account of WHO, which is funded at a factor of 3x over Members’ Dues by OECD countries and private donors; the UN/Accelerated Initiative for Access to Medicines; Product RED; the Clinton Foundation; the International Finance Facility for Immunizations, and product donations from industry requiring expenditures in storage and supply chain systems.
Both the GF and GAVI have the best of intentions in the operation of complex programs for some of the world’s most disadvantaged population groups. The problems noted above occurred largely within the 52 countries targeted by WHO as the primary intervention targets for a pandemic of influenza. They are also countries where unscrupulous government officials use a crisis to maximize their own personal wealth.
WHO provides institutional support and guidance within the UN community for approximately $9 billion in annual health disbursements. The GF audits and The Lancet findings suggest that WH0 has more than enough on its plate to manage effectively without adding a ten year PIP for an event that may not occur.
Now, in concert with PIP, WHO has been tasked to be the policy and program directing agency after the UN High-Level Meeting on NCDs in September. In November 2010, the Institute for Health Metrics and Evaluation at the University of Washington reported that of the $23.87 billion expended on international health, only 0.12% was for NCDs. Meanwhile, WHO provides this snapshot of how serious the problem is with NCDs:
- “80% of NCDs deaths occur in low and middle income countries;
- they create adverse—and underappreciated—economic effects;
- and, China alone will forego in national income over the next ten years $558 billion as a result of premature deaths caused by heart disease, stroke and diabetes.
While it is always better to be prepared, in a world embroiled by economic uncertainties, and less ODA flows today than yesterday, tough choices have to be made on health resource allocations. This environment forces a binary decision:
a. set aside US$2.283 billion over the next ten years for a potential pandemic from one infectious disease;
b. or, use the same amount of funds for an actual pandemic from multiple NCDs.
Choosing option (b) doesn’t negate (a) in the event of an actual pandemic of influenza in 52 of the poorest countries. It is in these countries that PEPFAR, GHI, GAVI, UNICEF, the Global Fund, and WHO have extant investments in laboratory capacity building, cold chain systems, and immunization programs. These resources could be re-directed towards an actual pandemic of influenza as its first line of defense. To finance an immediate intervention, these same countries have Special Drawing Rights from the IMF.
In the PIP proposal, industry’s record for in-kind product donations of 36.37 million doses of pandemic H1N1 vaccines in 2009 is documented by WHO. When the expected pandemic didn’t occur, industry was asked to take back a portion of these vaccines. Unfortunately, given FDA and EMEA regulations, they would have had to be re-labeled, a procedure that can be more expensive than the vaccines themselves. The countries where they were stockpiled faced an equally expensive vaccine disposal problem due EPA-type standards. In the event of a pandemic, there can be no doubt that industry would once again step up to its corporate responsibilities and make substantial in-kind donations.
NCDs are a neglected disease with real-time economic consequences for the developing world, particularly fragile states. Given alternatives for quickly deploying extant assets against a potential pandemic of influenza, it would be more prudent to apply scarce health resources to a known, virtual pandemic of NCDs. For instance, cancer in the developing world kills more than AIDS, TB and malaria combined—and CVDs kill more than the combination of these four disease categories in total.