Address at the Pedro Kouri Institute of Tropical Medicine
Dr Margaret Chan
Director-General of the World Health Organization
Dr Kouri, distinguished guests, colleagues in public health, ladies and gentlemen,
We face a challenging time, as public health struggles to position itself in a cross-current of strong trends. On one side, prospects for progress are battered by global crises on multiple fronts.
Last year, our imperfect world delivered, in short order, a fuel crisis, a food crisis, and the worst financial crisis seen since the Great Depression began in 1929. It also delivered compelling evidence that the impact of climate change has been seriously underestimated. All of these crises arise from policies made in sectors other than health. But all have profound, and profoundly unfair, consequences for health.
On the other side, prospects for progress are bolstered by unprecedented determination to solve long-standing problems and achieve greater equity in health outcomes. The Millennium Development Goals give this world its best chance ever to introduce greater fairness and balance into the very fabric of societies, especially for health.
The Goals are an extremely important corrective strategy, but they do not address the root cause of the great gaps in health outcomes seen within and between. The root causes reside in the international policies and systems that govern financial markets, economies, trade, and foreign affairs. These systems create benefits, but have no rules that guarantee the fair distribution of benefits. Equity is rarely an explicit policy goal.
Greed seeded the financial crisis, which sprang out of control as corporate governance and risk management failed at every level of the system. Climate change is now the price the world will inevitably pay for short-sighted policies. The pursuit of economic wealth took precedence over the protection of the planet’s ecological health.
As we all know, this region is especially vulnerable to the health effects of climate change, including more frequent and more severe extreme weather events.
In June of this year, WHO declared the start of the first influenza pandemic of the 21st century. This is another global crisis, and its management is largely the responsibility of the health sector.
In our response, we are seeing the best of the positive forces that shape cooperation for health in the 21st century. But we are also likely to see the consequences of decades of failure to care about equitable access to health care, and decades of failure to invest in basic health systems and infrastructures.
I have been asked to update you on the influenza pandemic situation and to discuss the implications of the response in terms of what it tells us about the character of international cooperation for health.
Ladies and gentlemen,
An influenza pandemic is a force of nature that takes its dynamic from the almost universal susceptibility of the world’s population to infection. Because the virus is new as well as readily contagious, it encounters no “firewall” of protection from pre-existing immunity as it sweeps through populations. A pandemic comes to an end when a sufficient number of people have acquired immunity, through either infection with the virus or vaccination.
Once an influenza pandemic is fully under way it cannot be stopped. Measures such as school closures, quarantine, or blocking the entry of symptomatic travellers at borders can slow spread somewhat. But a pandemic will come to its natural end only when sufficient herd immunity has been achieved.
The world has changed dramatically since the last influenza pandemic began in 1968. The interdependence of nations has increased in radical ways. International air travel has grown tremendously. At the same time, differences in income levels, in health status, in resources for health, and in response capacity are greater today than at any time in recent history.
When exactly the same virus spreads to every country, it will reveal what these great differences really mean for health.
The current pandemic is also the first major test of the revised and strengthened International Health Regulations. They have given the international community an orderly, rules-based way to act collectively, and we are reaping the benefits.
After a five-year nervous watch over the avian influenza situation in Asia, the world was much better prepared for a pandemic when another entirely new virus was identified in North America. The world was also probably more scared than it needs to be.
The new H1N1 virus spread internationally with exceptional speed. Aided by the volume of international air travel, the virus spread further in less than six weeks than past pandemics have spread in more than six months.
WHO continues to assess the impact of the pandemic as moderate. Worldwide, the overwhelming majority of patients have experienced mild influenza-like illness followed by full recovery within a week, even without any form of medical treatment.
To date, we have been fortunate in the way this pandemic has evolved. The virus initially spread in countries with good monitoring and reporting systems. For the first time in history, scientists could track the start of an influenza pandemic in real-time.
The sharing of information, viruses, diagnostic capacity, test kits, reagents, and research expertise was immediate and generous. This early experience established a strong precedent of international collaboration that continues to be followed. As countries now experience the second wave of spread, they do so with an impressive body of knowledge about the virus, its epidemiology, and the spectrum of illness it can cause.
The new virus was identified and reported to WHO in late April of this year. Genetic sequences of viruses have been rapidly placed in the public domain, and vaccine manufacturers in both developed and developing countries were freely given virus strains for vaccine manufacturing.
Constant testing of shared viruses, performed by laboratories in the WHO influenza network, has provided reassurance on several counts. We know the virus has not mutated to a more virulent form. We know that pandemic vaccines are a good match with circulating viruses. We know that the number of oseltamivir-resistant viruses is very small to date, with no onward transmission.
We know that H1N1 is now the dominant influenza virus strain, and this reduces the need for routine laboratory testing and simplifies the response. Once the virus begins to spread within a community, clinicians can assume that people presenting with influenza-like symptoms are infected with the virus. This frees laboratory diagnostic capacity to concentrate on the severe or complicated cases.
In the few months since the emergence of the new virus, doctors have acquired convincing evidence that oseltamivir and zanamivir, when administered within 48 hours after symptom onset, can reduce the severity of illness and the need for hospitalization.
This finding is important. Pandemic influenza is not the same as seasonal influenza for at least two reasons. First, it affects a much younger age group. In most outbreaks, nearly half of all infections have occurred in children and young adults under the age of 25 years. Most patients requiring hospitalization are from 20 to 35 years of age, with those requiring intensive care in the upper age range of this group. Fatal cases occur in a slightly older group of adults in their 40s and 50s. In contrast, around 90% of deaths during seasonal influenza occur in the frail elderly, a group largely spared by this pandemic.
Second, this virus can cause a very severe form of illness, again in a comparatively young age group and often in otherwise perfectly healthy people. Clinically, this is a virus of extremes. It does not seem to have a middle ground – either mild illness or very severe, life-threatening disease.
Concern is now focused on the clinical course and management of a small subset of patients who rapidly develop very severe progressive pneumonia. Treatment of these patients is difficult and demanding, strongly suggesting that emergency rooms and intensive care units will experience the heaviest burden of patient care during the pandemic.
Primary viral pneumonia is the most common finding in severe cases and a frequent cause of death. Secondary bacterial infections have been found in approximately 30% of fatal cases. Respiratory failure and refractory shock have been the most common causes of death.
Doctors who have managed such cases agree that the clinical picture is strikingly different from that seen during seasonal influenza. In severe cases, patients generally begin to deteriorate around 3 to 5 days after symptom onset. Deterioration is rapid, with many patients progressing to respiratory failure within 24 hours, requiring immediate admission to an intensive care unit.
Upon admission, most patients need immediate respiratory support with mechanical ventilation. However, some patients do not respond well to conventional ventilatory support, further complicating the treatment.
Findings from around the world now confirm that the risk of severe or fatal illness is highest in three groups: pregnant women, especially during the third trimester of pregnancy, children younger than 2 years of age, and people with chronic lung disease, especially asthma. Neurological disorders can increase the risk of severe disease in children.
Disadvantaged populations, such as minority groups and indigenous populations, are disproportionately affected by severe disease. Although the reasons for this increased risk are not yet fully understood, theories being explored include the greater frequency of co-morbidities, such as asthma and diabetes, often seen in these groups, and lack of access to care.
Although the exact role of obesity is poorly understood at present, obesity and especially morbid obesity have been present in a large portion of severe and fatal cases. Obesity has not been recognized as a risk factor in either past pandemics or seasonal influenza.
Just a few statistics help reveal the vulnerability of the world’s population during this pandemic. Obesity has increased dramatically since 1968, and is now being seen in epidemic proportions in rich and poor countries alike. WHO estimates that, worldwide, more than 230 million people suffer from asthma, and more than 220 million people have diabetes.
Moreover, conditions such as asthma and diabetes are not usually considered killer diseases, especially in children and young adults. Young deaths from such conditions, precipitated by infection with the H1N1 virus, are another worrisome dimension of the pandemic’s impact.
More than 99% of maternal deaths occur in the developing world, where they are directly linked to poor access to health care. The deaths of pregnant women during this pandemic will be tragic everywhere, but most especially so in the developing world, because the numbers will be so much greater.
Ladies and gentlemen,
Following extraordinary efforts on the part of industry and regulatory authorities, the first fully licensed pandemic vaccines became available less than six months after the new virus was identified.
UN calls for solidarity, especially in the sharing of medical interventions, were heeded. Supplies of antiviral drugs, made possible through industry donations, are now available in 121 developing countries. Hopefully, WHO will soon begin shipping stocks of pandemic vaccine to 96 developing countries that would not otherwise have access to vaccines. Cuba is, of course, included.
The situation is not ideal. As global vaccine manufacturing capacity is finite and inadequate, we are still several billion doses short of what is needed to fully protect all populations.
And the situation is not ideal for other reasons. In the best situation, international collaboration during a public health emergency should be unimpaired by any political barriers. I am fully aware of the impact that the economic, commercial, and financial embargo has on this country.
Under such circumstances, what you have achieved in terms of universal access to health care, outstanding health outcomes, and medical outreach to many countries in Latin America and Africa is truly remarkable.
The embargo is yet another example of how health can suffer from policies made in other sectors, for other purposes. It is beyond the power of public health, and beyond the mandate of WHO, to intervene.
Just as Cuban medical brigades have supported so many countries during crises, Cuba may very well need support during a public health emergency like an influenza pandemic. Rest assured of all possible support from PAHO and from WHO.